spitals and Health Agencies
HAVEN EMERSON, M. D.
ANNA C. PHILLIPS
lie Committee on Hospitals and Health Agencies
Council of Social and Health Agencies
803 PHELAN BUILDING
TELEPHONE GARFIELD 3524
SAN FRANC SCO PUBLIC LIBRARY
3 1223 90150 8474
Not to be taken from the Library
CiTY.PLANNI : COMMISSION
'CITY AND COUNTY OF SAN FRANCISCO
Hospitals and Health Agencies
HAVEN EMERSON, M. D.
ANNA C. PHILLIPS
The Committee on Hospitals and Health Agencies
Council of Social and Health Agencies
The Community Chest
5. F. PUBLIC LIBRARY
of San x> Bay Counties
Letter of Transmittal
To the Committee on Hospitals and Health Agencies of the Council of
Social Agencies of San Francisco,
Sharon Building, San Francisco.
The letter of your chairman, Dr. Ray Lyman Wilbur, of April 20th,
1923, and subsequent communications from the general secretary of the
Community Chest, Mr. H. J. Maginnity, made it clear that the objects
of the Survey of Hospitals and Health Agencies which I was asked to
undertake were :
1. To learn the present status of the work, and relations to each
other and to the community, of the various hospitals and health agencies
of San Francisco.
2. To prepare a program for safeguarding health and to provide
for the sick, which would meet the needs of San Francisco and could be
put into effect through the influence and resources bf the Community Chest.
3. To outline the relations and share of responsibility of the hospitals
and health agencies in such a scheme.
4. To suggest a plan for future development which will provide for
the growth of the population, not only in size but in the conception of
services which the medical and social sciences recognize as essential to
permit of the fullest safety and enjoyment of human life.
On June 11th the study was begun, and the field work was completed
on July 21st. The analysis of the data obtained and the preparation of the
report have been under way since August 20th. Miss Anna C. Phillips
has been associated with me, and responsible for most of the study of ad-
ministration of hospitals, and for the organization and direction of the
social and statistical studies of services for the sick.
Even though you are doubtless aware of the extent to which the
offices, resources in personnel and equipment, and the invaluable relations
of the Council of Social Agencies and of the Community Chest, were put
at our disposal, you cannot know the full measure of the patience, tact,
industry and unselfish devotion to the public interest which we met through^
out our period of study in San Francisco, from all to whom we appealed
for information, opinion and counsel, whether they were private citizens
or representatives of public or private agencies or members of the press.
A special acknowledgment is due to those who carried out the inquiry
into the condition of patients recently discharged from hospital care.
This study required of the field workers skill and experience in medical
and social needs and resources, particularly among the sick poor.
During the three weeks when the bulk of the field observations were
made, there were twenty-one persons engaged on part or full time in the
study, the equivalent of ten persons on full time, while much assistance of
the regular staff of your offices was given to matters directly contributing
to our work.
The cost of the survey, including the preparation of the report, has
been $5489.17. Printing of 1000 copies of the report as herewith pre-
sented will cost approximately $700.
Disregarding for the moment any possible benefits to accrue in the
future from such a study, it is not too much to say that the economies
suggested through the establishment of a central purchasing bureau, would
within twelve months reimburse the Community Chest for its investment
in the Survey.
Expressed in terms of added cost of hospital administration this
attempt at diagnosis or analysis of a community, as to its provisions for
protection against diseases and services to the sick, would add $2.18 to
the cost of maintaining each of the 2782 beds in the ten hospitals re-
ported upon in detail, or a charge of a little more than one cent ($0,011)
upon each member of the community in the year 1923.
Please accept the report herewith submitted in compliance with your
request and believe me,
(Signed) Haven Emerson, M. D.
October 27th, 1923.
437 West 59th Street
New York City
REPORT OF THE SURVEY
TABLE OF CONTENTS
SECTION I— THE COMMUNITY OF SAN FRANCISCO IN 1923 1
Area and Population 1
Vital Statistics 3
Death Rates 4
Birth and Infant Mortality Rates 4
Maternal Risk Rate 5
The General Situation 5
SECTION II— SERVICES FOR HEALTH AND ITS PROTECTION.... 6
Department of Public Health 6
Problems in Health Service 9
Health Education 9
Child Hygiene 15
Mental Hygiene 17
Venereal Diseases 21
Heart Diseases 23
Periodic Health Examinations 25
Health Council 26
SECTION III— SERVICES FOR THE SICK 27
Hospital Provisions and Community Needs 27
Organization and Administration 34
Services Rendered by Hospitals 39
(a) Extent of Use of Hospital Beds 40
(b) Services to Patients of Different Economic Groups 47
(c) Medical Services Maintained 54
Inadequacies of Medical Services 60
(d) Areas Served 66
Hospital Finances 70
Accounting Systems 73
Hospital Rates 76
Laboratory Charges ". 78
Hospital Council 80
Medical Services Provided 86
Organization and Control 91
Services Rendered by Dispensaries 92
(a) Dispensary Attendance — 1922 92
(b) New Dispensary Patients 98
(c) Areas Served 99
Dispensary Plants 102
I dispensary Finances 103
I lospital Social Service 105
( lhapter 4.
Visiting Nurse Service 112
Com alescent Homes 118
( Chapter 6.
Monies for the Incurables and Chronically Sick 123
SECTION IV— RECOMMENDATIONS 130
General Policies 130
Chapter 2. -.
Appropriations of Funds by the Community Chest 132
1. Basis for 1924 Appropriations 133
2. (a) Franklin Hospital . 133
(b) University of California Hospital 134
3. Lane and Stanford University Hospital 134
4. Osteopathic Clinic 135
5. French Hospital 135
6. Mary's Help and St. Mary's Hospitals. 135
7. Hospital Council 136
8. Health Council 136
9. Division of Child Hygiene ' 136
10. Social Service Departments 136
11. District or Visiting Nurse Association 137
12. Convalescent Homes and Homes for Chronic Invalids........ 137
Progress in the Field of Public Health 138
1. Health Education 138
2. Child Hygiene 139
3. Tuberculosis 141
4. Mental Hygiene 141
5. Venereal Diseases ..'...' 142
6. Heart Diseases 143
7. Cancer 143
8. Periodic Health Examinations .« 144
SECTION V— FORMS, LISTS, ETC 145
Letters to Physicians 145
Letter to Social Agencies 146
Cleveland Hospital Council Report Form 147
Convalescent Study Form 149
Long-Term Patients in Hospitals . 150
Survey of the Hospitals and Health Agencies
of San Francisco
The Community of San Francisco in 1923
For convenience of reference in understanding the discussion and the
relative importance of many of the matters which follow, a brief descrip-
tion of San Francisco so far as concerns the size, the area occupied, the
economic status, age and race groups of the population, and the elementary
facts of births, deaths and sickness, seems advisable.
AREA AND POPULATION
The land area of San Francisco, containing 46.5 square miles, or
29,760 acres, was on July 1, 1923, occupied by 539,038 persons, according
to estimates based upon the last enumeration by the Bureau of the Census
as of January, 1920. This is equivalent to a density of 18 persons
per acre for the entire area. Although there are other large cities of the
country with less concentration of population per acre, 1 few if any are so
free from districts or blocks where there is a dangerous density of popula-
The per capita property valuation of San Francisco, based on actual
or 100 per cent value of real estate, improvements and personal property,
is $2220 or a total of $1,196,580,000, higher than that of any city of over
500,000 population except Chicago.
Of the population under twenty years of age, which amounts to
26.2 per cent of the entire community, there is an excess of males over
females of about 2500. 2
The four important groups under twenty are about equally represented :
64.14 per 1000 of the population under 5 years of age
66.25 " " " " " 5 to 9
62.62 " " " " " 10 to 14
68.49 '\ " " " " 15 to 19
>y yy a
There is obviously some error in the figures offered by the San
1 Report of Committee on Municipal Health Department Practice. U. S. P. H. S. Bul-
letin No. 136, July, 1923.
2 Fourteenth Census of the United States, 1920, Vol. Ill, page 3.
Hospital and Health Survey
Francisco Board of Education for children from 5 to 14, owing partly
to the fact that reports from private schools are not compulsory, partly
to the incompleteness of teachers' class reports, and partly to the failure
to take into account the 4 per cent to 6 per cent of children of these
ages who should attend school but are generally not found or brought
under school control.
In January, 1 () 20, actual enumeration by the Federal Census Bureau
showed there were in San Francisco, between the ages of 5 and 14 years,
32,624 boys and 32,718 girls, a total of 65,342.
In October, 1922, the San Francisco Board of Education reported
55,952 hoys and girls of these ages, although since the time of the federal
census of 1920 the city had gained 25,000 in population, of whom about
3200 are estimated to be children between 5 and 14 years of age. It is
probably safer to use the Federal Census Bureau figures than the reports
of the Board of Education in this particular.
While the city has been arbitrarily divided into four districts for the
convenience of administration of the functions of the Board of Health,
the facts of population, births, deaths, sickness, etc., are not recorded so
that analyses can be made of the relative safety of life, or in the matter
of health liabilities and assets district by district. The experience of the
city of New York in assembling all its vital records by so-called sanitary
areas which correspond to multiples of the census enumeration districts, has
been so valuable to the social, religious, medical and health agencies of the
city that it can be confidently predicted that similar advantage would
follow the adoption of a comparable area basis for San Francisco's human
Certainly, it is impossible to give that detailed epidemiological study
to race, industrial and economic groups of the population, which is required
by modern science when a city of 500,000 is considered as a unit rather
than as a composite of numerous distinct areas or neighborhoods, each with
its separate needs and resources,
The four districts as defined in the operation of the Department of
Public Health are not on an equalized area basis, and furthermore, com-
parable and complete reports of births, deaths and sickness are not re-
ceived or tabulated for all four districts.
We must, therefore, picture the situation for the city as a whole,
disregarding differences in birth, death and sickness ratios in different
parts of the city, which probably vary as widely in San Francisco as in
other cities. For instance, the tuberculosis mortality in the Riverside dis-
trict of New York City is 50 per 100,000, while in the Bowling Green
district it is 1171 per 100,000. Only by subdivision and analysis of the
3 Statistical Sources for Demographic Studies of Greater New York, New York City
1920 Census Committee.
The Community of San Francisco in 1923
population of a city upon a district, or permanent equalized area basis, can
the need for and distribution of preventive and relief resources be clearly
The three features of the population of San Francisco which bear
particularly upon the problems of health and sickness are, the considerable
floating population, characteristic of great seaport cities, the colony of
8000 Chinese within the city and about 5000 more in the bay region
who look to San Francisco for medical relief and care, and the Italian
colony in the Telegraph Hill region. Owing to the lack of district analysis
of the city above referred to, and to the absence of hospital records which
would make a study of sickness and deaths among the transient or non-
resident population of San Francisco possible, further comment upon these
particular features is impracticable.
Among the large cities of the United States, San Francisco is notable
for the relatively high proportion of native white stock among its popula-
tion, the high standard of living, the extent of self-support, and the con-
sequent self-respect and absence of widespread pauperism and degrada-
tion which prevails among the recent immigrants from the South European
countries, whose presence in large numbers and in congested tenement
colonies has created such serious relief and medical problems in many of
the eastern seacoast and industrial cities of the countrv:
I. Population by Age Groups Per 1000 of Total Population for New York and
San Francisco, 1920
20 and 40 1000
Number Ratio Number of Ratio
Over per years per
40 years 1000 Unknown 1000
II. Per Cent of Populations of Native and Foreign Parentage
Native Born Whites
of Native Parentage
New York Per Cent
Native Born of
III. White Population of San Francisco, 1920, by Foreign Parentage Groups
(Native Born of Foreign Parents and Foreign-Born Whites)
Austria . 9,983
Mexico • 5,180
Central and South America.. 2,005
Others under 2000 9,923
Mixed Foreign Parentage. . . .20,814
4 Hospital and Heai/th Survey
Two further facts appear to be significant in the matter of population,
the very low birth rate of the city and the high cancer death rate, which
give evidence of an age grouping of the population with a higher propor-
tion in the decades over forty than is the case in other cities with higher
birth rates and lower cancer death rates. The situation can perhaps be'st
be illustrated by the following summary for San Francisco and New York
Rates per Thousand of the Population Per Cent of Popu-
Birth Rate Cancer Death Rate lation over 40
San Francisco 16.6 (June '22-May '23) . ...1.51 32.8 (1920)
New York 23.2 (1921) 97 25.99(1920)
During the twelve months, June 1922 to May 1923 inclusive, there
were 7149 deaths, giving a death rate of 13.26 per 1000 of the population,
without correction for non-residence, race, sex, or age. San Francisco's
general death rate would be considerably lower if it were corrected for
the age groups of the population, according to standard statistical practice.
The fluctuation in the general death rate from month to month is much
less than is common in cities with a more rigorous climate and where wide
changes of temperature distinguish the seasons. This is a fact of much
importance as will be seen in studying the similar uniformity in use of
hospitals throughout the year. The months of highest general death rates
are January, February and March, due apparently mainly to the increase in
deaths from pneumonia in these months, February and March showing
also the high periods of hospital occupancy. While May and September
show the least use of hospital beds, it is in June, July and August that
the general death rate is lowest. (Chart B, page '45. )
More than half of the general death rate from all causes (6.78 per
1000 of the population) is due to deaths from pneumonia (.57), all forms
of tuberculosis (1), violence (1.12), cancer (1.51), and diseases of the
heart (2.58). The very low typhoid fever death rate (.03) gives an ex-
cellent index to the sanitary quality of water and milk supplies and the
disposal of human waste.
BIRTH AND INFANT MORTALITY RATES
There were 8557 babies born in San Francisco in the twelve months
Tune 1922 to May 1923, of whom 436 died before they were a year old,
giving an infant mortality rate of 50.95 per 1000 living births. The infant
mortality rate for 1922 (57), was lower than that of any city of 100,000
population or over in the United States except Seattle (49), Minneapolis
(53) and Portland, Oregon (56).
The birth rate of San Francisco in 1922 was 16.6, lower than that
of any of the larger cities of the country except Los Angeles (16.2). In
the twelve months, June 1922 to May 1923, the birth rate was 15.8.
The Community of San Francisco in 1923
Of all the births reported, 10 per cent were by midwives and about
65 per cent from hospitals. No other of the large cities of the country-
shows so large a proportion of all maternity cases cared for in hospitals.
MATERNAL RISK RATE
In 1922 there were 8656 living births and 195 stillbirths reported, or
a total of 8951 pregnancies. There were 60 deaths of mothers from
causes connected with childbirth, giving a maternal risk rate of 67.03 per
While this rate is not particularly high for cities in the United States,
it is much higher than the maternal risk rate in several of the cities of
England where rates of 38 are recorded. It is probable that the high
maternal mortality is in large part due to the inadequate development of
prenatal care of expectant mothers, only a small per cent of whom receive
consistent medical supervision from the fourth month of pregnancy onward.
THE GENERAL SITUATION
We see San Francisco, then, as a city favorably located as to topog-
raphy and climate for the maintenance of excellent sanitary standards of
With a protected water supply, and the assurance of adequate increase
to meet the demands of the future, with an easy and safe provision for
disposal of human waste, with few, if any, of the inconveniences or hazards
of industry to handicap its citizens, San Francisco faces chiefly the health
problems caused by the presence of various common communicable diseases,
and the widespread unfamiliarity of its people with the means of self-
protection and lacking information based on modern biological science,
upon which the development of sturdy, vigorous bodies and the training
of alert and well-balanced minds and nervous systems depend.
Generosity and initiative, confidence and determination to succeed in
providing health protection and care for the sick, have characterized San
Francisco's accomplishments to date.
From now on, concerted action, accurate analysis, keen imagination
and long distance planning will probably be the notable features of the
universal co-operation which has crystallized in the formation of the Com-
Services for Health and Its Protection
While it can be fairly argued that all services for the sick contribute
directly or remotely to the health of the community, there are sufficient
differences in function between the agencies dealing primarily with health
and its protection, and those which have been created for the diagnosis
and treatment of disease, to justify separate consideration of them.
For convenience of presentation we may best consider first the or-
ganization and activities of the Board of Health and then discuss under
functional headings other important services developed chiefly under
separate auspices and in process of transfer to public authority.
THE DEPARTMENT OF PUBLIC HEALTH
The method of appointment, the qualifications, and the terms of service
of the members of the Board of Health meet the best standards of munici-
pal practice. It is, however, not considered a wholly suitable situation
which imposes upon the same directing body responsibility for the highly
technical work of providing hospital care for the sick poor of the city and
for the domiciliary care of the aged and infirm indigents, as well as for the
development of the many types of medical and social resources which must
be used for the protection and maintenance of health. As the city grows
and the burden of these several services becomes unbearable, there will
surely be needed a board of trustees for the San Francisco Hospital, with
its special divisions for isolation, for tuberculosis and for leprosy, and its
chain of four outlying emergency hospitals, the Relief Home, etc., which
will bear the same relation to the superintendents of these institutions as the
Board of Health does to the Health Officer. Progress in public health
work in San Francisco would doubtless have been faster and have received
more support if a great part of the time and energy of the Health Officer
and of the Board of Health had not been so constantly concerned with the
operation of the largest plant for the care of sickness in the city, a negative
function so far as modern public health work is concerned.
The fact that the Health Officer holds his position under Civil Service
rules, makes for permanency of tenure and a most desirable continuity of
The annual budget for the Department of Health is presented to the
Board by the Health Officer and when approved by them, is submitted to
the Mayor and Board of Supervisors. Of the total appropriation of about
$2.75 per capita for the Board of Health, only S7y 2 cents per capita was
devoted to health services proper, a sum which in 1923 was less than that
Services for Health and Its Protection 7
appropriated for similar functions in any of the cities of the country of
over 500,000 population, except St. Louis and Chicago.
Aside from the Division of Hospitals and Charities which deals with
the care of the sick and the poor of the city, the functions of the Board
of Health, as carried out by their executive, the Health Officer, are the
Sanitary supervision of public property and institutions, together with
the abatement of nuisances.
Enforcement of pure food laws, including control of eating places,
food handlers, meat, milk and dairy products, etc.
The control of communicable diseases, with particular attention to
tuberculosis and venereal diseases, in special clinics.
Protection of maternity, infancy and childhood through prenatal and
baby stations, and school medical inspection, supervision of foster homes,
midwives, etc., under the Division of Child Hygiene.
Epidemiology and vital statistics.
Diagnostic laboratory service.
The services provided out of the appropriations are probably as well
balanced and effective as the funds permit, but it is suggested that less
emphasis upon environment and the details of sanitary supervision with a
corresponding increase in the detection and isolation of the common com-
municable diseases of childhood would show more direct results in reducing
preventable sickness and death.
It is obvious that with so very limited an appropriation for public
health services, about one-half the per capita amount made available in
Detroit and Toronto, the Health Officer cannot carry on many of the
profitable activities recognized as fundamental. An excellent picture of
a well-balanced and adequately supported municipal health department for
a city of 100,000 is to be found in the Report of the Committee on
Municipal Health Department Practice of the American Public Health
Association, U. S. Public Health Service Bulletin 136, July 1923, pages
247 to 274.
If the Board of Health should adopt as its program the development
of health services suggested in this report, it is probable that the force
of public opinion and the powerful influences of the private health agencies
of the city would soon be so strong in support that adequate appropriation
would be obtained.
Where the two functions, care of the sick and protection of health, are
carried out by the same executive or under the same department of govern-
ment, it is almost inevitable that the more pressing demands of immediate
suffering will be generously met while the less obvious work of prevention
lags for lack of public understanding of its significance.
The work of the Department of Health has been observed and instead
of including here a record of volume or quality, only such functions as are
seriously handicapped or wholly unprovided for will be discussed, to
point out some of the major problems which might well engage the
8 Hospital and Health Survey
attention of a Health Council if such a study and program group is
created under the auspices of the Community Chest.
Protection against diphtheria by the widespread demonstration of
toxin-antitoxin immunization of young children (at 2 years of age) requires
additional medical and nursing personnel and an expansion of educational
The problems of tuberculosis and venereal disease control are treated
of later in this section, but it is obvious that satisfactory efforts at control
of these diseases will depend largely upon the more complete reporting of
patients by physicians, and better facilities for treatment of groups of cases.
Protection of maternity and childhood is seriously hampered by lack
of personnel to supervise midwives, to offer prenatal instruction, to examine
children of the pre-school age and to provide a thorough medical inspec-
tion of children in school and in industry.
Public health nursing under the Department of Public Health is
carried out by 28 school nurses, 5 infant welfare nurses and 9 tuberculosis
nurses. Six of the cities of 500,000 or over spend more than San Francisco
per capita for their public health nursing under a health department. (San
Francisco $0.07, Pittsburg $0.09, Los Angeles $0.09, Buffalo $0,093, New
York $0.10, Baltimore $0.14, Detroit $0.22.)
Laboratory service and food, milk and dairy inspection are suitably
Plumbing and housing inspection are properly functions of a building
department and as carr ied out co rjtrihivt^ little to the health of the
The final step in protection of the water supply by chlorination having
been made, this is no longer a sanitary problem.
The gradual elimination of privies is quickly bringing this potential
nuisance and sanitary risk to an end.
Health education is wholly unprovided for and in this appears the
most striking inadequacy of public service by the Board of Health.
Reports of births, deaths and sickness, the analysis of their distribu-
tion by race or nativity, by age, sex and city district, by week or month
of the year in comparison with the experience in previous years and in
other cities, constitute the elements of health bookkeeping and epidemiol-
ogy. Provision is not made for suitable tabulation of these facts and no
annual report is published, thus depriving the citizens, as well as the public
and private agencies dealing with health and disease, of a means of
education and valuation of work done or uncompleted, which is of the
In summing up the situation so far as the Health Board and its
Divisions of Hospitals, Charities and Health are concerned, it appears that
San Francisco, with a high per capita wealth, provides with much gener-
osity for the sick but is rather parsimonious in its appropriations for pre-
vention of disease. This is probably due to the lack of public information
upon the subject of health, the possibility of attaining it, and the necessity
of paying for it.
Services for Health and Its Protection
PROBLEMS IN HEALTH SERVICE
As each of the major issues of preventive medicine has received special
attention, it has become increasingly apparent that no preventable disease
which is widely prevalent can be handled as a problem apart from other
disease or from the social and economic problems of the entire community.
Few health problems are limited to the poor or rich alone, to the factory
hand or the mother in the home. As a result of a broader recognition of
the interrelationship of causes and effects of diseases, we have seen first
one and then another of the special campaigns and private organizations for
health protection gradually enlarge the scope of their respective programs
to include all groups in a community.
It is not an exaggeration to say that at present the tuberculosis, child
hygiene and venereal disease programs cover an almost equally wide field
and that the logical completion of any one would constitute a suitable com-
munity health service.
Similarly, mental hygiene touches very closely child hygiene work at
almost every point, and heart diseases cannot be checked without further
progress in control of syphilis and the communicable diseases of childhood.
Even though cancer is so nearly the burden of one age group, the
relation of maternity, personal hygiene, occupation, syphilis, neglected
teeth, etc., to certain types and locations of malignant growths brings the
cancer campaign into necessary relationship with other fields of preventive
From these brief suggestions it can be inferred that no precise separa-
tion of functions, no isolation of agencies, can be allowed in public health
work, and furthermore, that in no other phase of community relationships
is there a greater need of central direction, of accepted leadership and of
close association among the workers to prevent confusion of opinion,
duplication of effort, and waste of public and private funds.
There is at least one element in every phase of public health work
upon which efforts and resources can be combined, namely, that of educa-
tion in health.
San Francisco has made no provision for educational service under its
Board of Health, although it is now almost ten years since the Bureau of
Public Health Education was established in the Department of Health of
New York City, and fifty-two of the eighty-three cities of the country of
over 75,000 population carry on enough educational work to demand a
head for this activity under the health officer. Thirty-nine of the eighty-
three cities publish regular bulletins. Occasional lectures by the Health
Officer of San Francisco, and by the doctors and nurses of the staff,
10 Hospital and Health Survey
and a portable exhibit, constitute the only health educational work of the
Health Department. There is no bulletin or annual report, no press service,
no systematic stressing- of seasonal dangers, or successes in diminishing
There is a similar lack of policy and provision for health teaching
among all the private agencies, except the Tuberculosis Association, in
spite of the fact that instruction to the individual is the basis of preventive
work for the expectant mother, the school child, the families of the tuber-
culous, as carried out at the clinic and at the bedside.
The exceptions are the newspaper publicity and instructional service
carried out by an organization of physicians, developed primarily to pro-
tect the medical profession and the public against the mischievous propa-
ganda and attack of cults and quacks, and the weekly bulletin of the Cali-
fornia State Department of Health, which has but a limited circulation in
San Francisco, chiefly among the doctors, nurses, teachers and ministers.
Of course, there are lectures given on the prevention of cancer, on
child hygiene, on tuberculosis, etc., to occasional audiences, but there is
nothing in San Francisco that can be called an educational policy for any
age group or class of the community, planned and carried out year after
year with the definite object in view of giving the reading and understand-
ing public all they can use of the abundant knowledge of the causes and
means of preventing disease.
Xor is there in the schools of the city such a system of progressive
teaching of health habits, of the simple facts of biology, and of their
application to the common situations of personal, family and community
life as will arm the child against preventable disease, against superstition,
fear and ignorance in health matters.
Until the police power of the State, as expressed in the authority of
the Board of Health, and the services for the sick are supplemented by
an aggressive continuous education of the community, and particularly of
the school children in the meaning of health, the way it may be attained
and the causes of its destruction, no permanent impression will be made
upon the most important causes of human disability.
The methods, the subject matter, and the costs of public health educa-
tion are well known.
To accomplish results there are needed :
(a) Inclusion of teaching of health habits, of personal hygiene, of
health protection in the schools.
(b) The establishment of a division of health education, with an
appropriation of approximately $20,520 4 in the Department of Health.
(c) A conference group or committee of the proposed Health Coun-
cil devoted to the study and promotion of health education by public and
4 Report of Committee on Municipal Health Department Practice, U. S. P. H. S. Bul-
letin No. 136, July, 1923, page 273.
Services for Health and Its Protection 11
private agencies. Membership might properly include representatives of
the Board of Health, the Board of Education and of the private health
San Francisco has been so favored by the initiative of its professional
medical and social teachers and students of tuberculosis, that organization
and services have followed closely upon plan and program, until at present
most of the facilities required are provided.
Excellent analyses of the tuberculosis situation have been made within
the past two years, and reports based upon these, already in the hands of
the Council of Social and Health Agencies, were studied. It is not neces-
sary to do more than refer to these careful studies and emphasize their
The following brief headings give an excellent picture of the re-
sources, the results and the present needs as understood by the San
Francisco Tuberculosis Association :
Defining the Tuberculosis Problem in San Francisco
I. MACHINERY FOR THE CONTROL OF TUBERCULOSIS
1. Bureau of Tuberculosis, Department of Public Health, with a chief in
charge of six Chest Clinics throughout the city, eight visiting nurses, who follow-
up patients in the homes, educate families, and bring contacts to clinic. One
supervising nurse at hospital in charge of clinics and follow-up.
2. Tuberculosis Hospital, Department Public Health. Two hundred and
forty beds for all types of tuberculosis in adults. Highest type of plant and
3. San Francisco Tuberculosis Association, an organization dedicated by pri-
vate endeavor as a laboratory where methods for fighting tuberculosis may be
initiated and demonstrated and their administration ultimately turned over to the
proper public authority.
4. Semi-philanthropic institutions out of town: Arequipa Sanatorium (46
beds) for early tuberculosis in wage-earning women, for educational work and
research; San Mateo Preventorium for Boys (15 beds); Stanford Convalescent
Home (16 beds) for children; Hill Farm (40 beds) convalescent home for children.
5. Child Welfare Program of the Department of Public Health with eight
health centers, including prenatal instruction, well-baby clinics, supervision of
boarding homes for children, examination of children of pre-school drive. Also
children's clinics in eight hospitals and one private health center.
5 (a) Communication (January 16, 1922) from, Dr. William C. Hassler, as Chairman
of the Health Agencies Section, to H. J. Maginnity, secretary Council of Social and
Health Agencies, pages 5-9.
(b) Community Resources for the Control of Tuberculosis According to Age Periods;
Prevention and Treatment for the Child of Preschool Age; The School Child; The
Youth (16-25), by Miss Elsie Krafft of the San Francisco Tuberculosis Association.
(c) Follow-up Study of San Francisco Tuberculosis Hospital. Presented at the
California State Tuberculosis Association, February 3, 1922. Miss Elsie Krafft.
(d) Annual Report of San Francisco Tuberculosis Association, 1922. William Ford
Higby, general secretary. Mortality Tables; Community Resources; Health Training;
(e) Excerpt from Report of Survey of Tuberculosis Clinics of California. National
1- Hospital and Health Survey
6. School Health Program through co-operation of Department of Public
Health, Board of Education and San Francisco Tuberculosis Association. Child
Health Education in twelve schools, Nutrition Classes in twenty schools, Bread
and Milk Lunches in all schools, Intensive Health Work in one school, two out-
door schools with clinic service and follow-up Board of Health nurses. Five
>chool doctors, 23 school nurses, 7 dentists, 1 dental hygienist, 1 optometrist. '
7. Health Education: Health service in dailies, Radio Health Talks, Uni-
\ ersity Extension Courses, Public Health Committees, San Francisco Center.
S. Outdoor Life Program of Boy Scouts, Camp Fire Girls, Y. M. C. A.,
Y. W. C. A., Playground System throughout city. Many vacation camps in
summer and two vacation homes for children, five for girls and young women.
9. State aid to children of tuberculous parents, free milk and eggs from five
relief agencies and supplemental aid to families. Children committed to Chil-
dren's Agency through Juvenile Court and given special care and supervision.
10. Legislative basis for work in regulations for pure milk and inspection,
pure water and food supply, reporting of contagious diseases, interstate carriers
II. IS THE MACHINERY EFFECTIVE?— ACCOMPLISHMENT
1. Reduction of death rate from 330 per 100,000 of population in 1900 to
109 per 100,000 in 1922.
2. Development of clinic system from one central clinic in 1909 to six clinics
throughout the city in 1922. Growth of clinic attendance from 1599 in 1909 to
5981 in 1922. Three hundred and forty-six new cases in 1909 compared with
1804 new cases in 1922.
3. Development of visiting nurse system from 2 in 1908 to 8 in 1922 and
1 supervising nurse from the association, resulting in increase of home visits from
16 in 1908 to 9898 in 1922.
4. Reduction of undernourishment in children from 11 per cent in 1921 to
2.5 per cent in 1922.
5. Finest municipal tuberculosis hospital in the United States, with high
type of medical care.
6. Passage of amendment authorizing country sanatorium.
III. GENERAL COMMENT
1. Xot enough hospital beds. Total annual deaths, 637. Allowing one bed
for each annual death, reveals the inadequacy of the present 240 beds.
2. Total annual deaths include forty-eight children under 10 years. But
there is no children's ward in the Tuberculosis Hospital, and no other facilities
for their care in active cases
3. Inadequate registration. Registration for 1922, 1533 active cases, or 2.4
cases to a death. Average registration in most cities, 3 or 4 cases to a death.
4. Failure to reach cases in early stages. Majority of cases admitted to
Tuberculosis Hospital are moderately or far advanced. Fifty per cent die in
the hospital. No sanatorium for early cases in men such as Arequipa is for
5. Difficulty of the migratory tuberculous. Fifty per cent of the patients
in the hospital are floaters.
6. Need of better housing facilities for single homeless men.
7. Food-handling jobs, a favorite with ex-patients and no law to prevent.
(Ordinance now being framed.)
8. No facilities for the industrial rehabilitation of discharged patients. (Plan
Services for Health and Its Protection
9. Inadequate industrial health service. Only fifty welfare departments and
only twelve with medical examinations. Survey being made, shows failure to
The thorough study of the subsequent history of tuberculous patients
discharged from the San Francisco Hospital is a model worthy of imitation
by other cities. The situation is briefly expressed in the following
The immense waste evidenced in all these figures reveals the inadequacy of
one hospital unit to cope with the problem, even when that unit is supplemented
with a follow-up system. The hospital renders invaluable service in the commu-
nity program for control of tuberculosis by segregating and caring for far-
advanced and dying cases which would otherwise be a menace to public health.
But this solves only part of the problem. Three links are needed: (1) The hos-
pital itself; (2) The country sanatorium; (3) A half-way house between the wards
and the working world. Our country sanatorium is about to be realized. What
is now wanted is a workshop where, under medical supervision, discharged
patients could be trained in new occupations within their strength, Combined
with it, but preferably under separate management and separately housed, should
be a boarding-house where they could be properly fed and lodged and supervised
until they reach normal health and working capacity.
It is significant that the patients reported well and working are those who
had some education and training that made possible a less strenuous type of
work than the average. Among them are engineers, carpenters, painters, motor^
men-, tailors, garment-cutters, salesmen, clerks, a radio-operator, a photographer,
and a mechanical dentist.
Seeking an expression of opinion on the workshop idea, a letter was sent
out, and all those possible to reach personally were interviewed. Hearty endorse-
ment came from various parts of the country, from those who were struggling
on part-time work, as well as from those who had experimented successfully for
themselves and wanted to see others try. While a pathetic few, concluding that
the workshop was already in operation, called at the hospital to begin work!
With a country sanatorium and a workshop to make more effective the
function of the hospital, undoubtedly we could change the vicious circle here
represented, into a back-to-health-and-economic-efficiency cycle for a large num-
ber, with a great saving of money and medical skill:
Following the Fruit
Walking the Ties
Working in Kitchens
Back to City
1"* Hospital, and Health Survey
Among the significant findings presented in the foregoing report are
those dealing with the readmission of tuberculous patients to hospital care,
and the subsequent history of patients discharged from the San Francisco
Tuberculosis Hospital :
"Readmissions to the San Francisco Tuberculosis Hospital in a three-year
period — 195 patients.
Second admission 179
Third " '. ..V '.['.'.'. 19
Fourth " ' 5
Fifth " ;.;;;; i
Two of the cases total ten years in the hospital on readmissions and one
Of the 914 cases investigated we have these figures:
Found living 255 Left the city 175
Dead 218 Left the State 56
Still missing 441 Went to the country 61
Went south . . 50
Of the 255 found living:
Well and working 88 or 34%
Again in S. F. Hospital 46
In other hospitals 46
In Relief Home 30
Reporting to our clinics 58"
The Annual Report of the San Francisco Tuberculosis Association for
1922 in the following important statements puts the matter tersely:
"A decline of 48 per cent in the death rate from tuberculosis is noted
since 1910. The greatest decline is noticed in 1906, during the period of
the earthquake and fire. The death rate in 1905 was 322.2 and in 1906,
In the tuberculosis field alone has there been any thoroughgoing plan
formulated and carried out, as far as resources permitted, for widespread
instruction in the preventable causes of disease and the personal and com-
munity resources for its control. The demonstration and research work in
the Daniel Webster School, in the study of the incidence and reduction of
nutrition, and elsewhere in various phases of medical, social and administra-
tive work for the tuberculous, reflects great credit upon the character of
direction, initiative, and public service of the San Francisco Tuberculosis
The study of the National Tuberculosis Association brings out the
fact that a more nearly complete reporting of tuberculosis should and can
be accomplished, and emphasizes the extent and result of shortage of beds
for active cases of the disease:
There were in San Francisco County but 1205 cases reported in 1921, most
of these being in the city. The number of reported cases is very low, indicating
a lack of co-operation of the medical profession with the Board of Health. The
Commissioner of Health has carried on a follow-up campaign to gain better
co-operation, but thus far has been only partially successful. That physicians can
and will co-operate, when sufficient pressure is brought to bear, is shown by the
number of reported cases in New York City and Chicago.
Services for Health and Its Protection
The shortage of beds means that hundreds of far-advanced cases are living
and dying in their homes, many of them among children. Eight active cases for
every annual death is a conservative ratio. There are, therefore, at least 4350
active cases in San Francisco.
Attention is called also in this study to the shortage of public health
nurses, to the lack of training of the nurses now engaged in this work,
the special problems of tuberculosis visiting and home supervision, the
need of expert supervision to raise the standard of field work, the in-
completeness of clinic records and the inadequacy of home follow-up of
The study suggests the considerable advantages to be obtained . in
planning local work, by analyzing the distribution of deaths from tuber-
culosis by race and age groups, as expressed in the following tables :
Tuberculosis Deaths by Race and Age
Under 1 year. . .
• • • ■ • «
1 to 4 yrs.. . .
5 to 14 "
15 to 24 " ...
25 to 34 "
35 to 44 "
. ... 143
45 to 54 "
55 to 64 "
.. . 60
65 and over ....
It has been remarked above that certain phases of public health work
are so all embracing that a complete program for either one of them would
constitute a satisfactory community service. Certainly if San Francisco
could put into effect the entire plan for the protection of maternity and
childhood which the leaders in this city in these specialties of preventive
medicine have though out, the accomplishment would be notable.
The Health Officer, the teachers of pediatrics, obstetricians, women's
organizations and various social agencies appear to be in entire agreement
as to the desirable elements which should be included in a child health
Upon the structure of the health centers established primarily to reduce
infant mortality, and with the well-established medical and nursing service
in the public and parochial schools, both under the Department of Health,
there has been built a constantly broadening service often depending upon
private resources to initiate, demonstrate and popularize new phases of the
work, but in the long run all functions appropriate for public operation
gradually being assumed by the Board of Health as the proper burden of
Recent studies have been made by the Public Health Committee of
the San Francisco Center of the California Civic League upon the extent
16 Hospital and Health Survey
and character of care given to the expectant mother and to the mother
and child during* the post-partum or neo-natal period.
That this was needed is apparent from the still high mortality rate of
infants under one month of age and of mothers from puerperal causes, as
can be seen from the following table:
1918 1919 1920 1921 1922
Total Births 8466 8386 9044 9167 8656
Deaths Under One Month 115 304 325 212 289
Deaths of Mothers from Puerperal Causes.. 42 71 83 56 60
Prenatal supervision is recognized now as an obligation of the Health
Department and of the maternity services of hospitals, but the standards of
much of this work are low, the mothers are not commonly reached until
they are well along in pregnancy, often in the seventh and eighth month ;
Wassermann reactions are not taken as a routine, education of the mothers
is undertaken without a preliminary medical examination, urine tests and
blood pressure observations are. not made uniformly and there is rarely
any follow-up of the patient in the home to secure good personal hygiene.
The standard of prenatal work at Mount Zion and at University of
California and Lane and Stanford University Hospitals, is excellent.
Post-partum follow-up in the homes is not carried out adequately as
a rule, though here, as in the prenatal work, both quantity and quality of
service are improving.
The lack of complete prenatal and of any post partum care, at the
San Francisco Hospital causes much difficulty for women who must, for
these periods, look to this hospital's clinics for attention.
While the effort at the Haight Street Clinic or Children's Health
Center is entirely laudable as a private undertaking, it is obvious that
education alone will fall short of the service needed if it is not supple-
mented by medical examination and supervision of the expectant mother by
nurse visits in the homes and such exact methods of diagnosis as the use
of the Wassermann test and tests of urine and blood pressure.
The standards adopted several years ago and steadily maintained and
increased in the work of the Maternity Center Association in New York,
are nowhere observed in all their completeness in San Francisco.
The time of one nurse is not suffitient to carry out adequate super-
vision of the 105 licensed midwives, the problems of whose nationality,
education and racial customs are of themselves no small matter for ad-
justment to the standards of the Board of Health.
Nationalities of 105 Midwives
Italian 37 English . 2
Japanese 24 Spanish 2
Russian 8 Belgian
United States 8 Chinese
German 7 Danish
Swiss 5 Hungarian
Unknown 4 Serbian . .
Austrian 2 Swedish .
Services for Health and Its Protection 17
Supervision of well babies lacks only in volume of service to meet
all reasonable expectations and the results to date are admirable. A report
of five months' study of the whole range of health work for children was
made by the Committee of the San Francisco Civic Center. The con-
clusions submitted express in general the best opinion of the city and should
be used as the basis of arguments before the public authorities.
The substance of the matter is the fact that the appropriations for the
Department of Health are too meager to provide sufficient doctors and
nurses for health center, infant, pre-school, and school child supervision,
and an organization which would justify and require the full time of a
specialist in child health as the chief of a bureau.
This will all doubtless come about when education of the public and
the public officers is insistent and continuous.
The detailed recommendations to complete the child health program
prepared after individual and group conferences with those who have
studied the children of San Francisco as no brief survey could possibly do,
will be found in Section IV.
Too much praise cannot be given to the departments of pediatrics
at the two university medical schools which have made their teaching
staffs and their clinics available in countless ways to supplement the work
of official and private agencies devoted to child welfare. They are carry-
ing on active research in clinical and administrative problems in schools
and health centers.
In San Francisco there is just one free bed designated for the care of
patients suffering from mental disease. There are a few beds in privately
supported hospitals where those able to pay three dollars a day or more
can receive attention, but it must be explained that nowhere in the city is
there hospital or clinic service where the resources or environment and
personnel now known to be essential or at least desirable for the diagnosis,
observation and treatment of mental and nervous disease, have been as-
sembled for either the rich or the poor.
There is no greater lack in the entire scheme of hospital and health
services in this city than in the field of mental disease, whether for treat-
ment or prevention.
Fortunately, however, this rather astonishing inadequacy which is
rather typical of Pacific Coast cities, is not due to rivalry or controversy
among those informed on the subject.
In February of this year, the President of the Board of Health
declared in no uncertain terms his conviction as to the importance of the
mental problem of San Francisco, and the fact that it was a burden for the
community to assume through public agencies primarily. We can do no
better than to quote from his ringing appeal for a radical change in the
attitude of the public toward mental disease, for a change in the method
18 Hospital and Heai/th Survey
of commitment and for immediate provision for mental disease patients
in the temporary or curable stages of these states in the San Francisco
Hospital (San Francisco Examiner, February 12, 1923) :
There is a growing and imperative demand coming from all quarters, medical
and lay, for a change in the manner of caring for and committing insane patients.
This demand does not concern the acutely insane alone, but includes what are
called "border-line cases" or, to use a common expression, the cases of all of
those persons who are "acting queer." The demand is for provision of proper
hospital conveniences for the deliberate observation of all cases of the mentally
afflicted by trained psychiatrists. ....
As a member of the Board of Health, the conviction has been forced upon
me more and more strongly in the last year or two that we are not doing our
full duty when we fail to offer a place of refuge to those needy persons who are
verging on mental incapacity or are subject to some form of mental disturbance.
The mandate of the charter makes no distinction between the poor who are
physically ill and those who are suffering mentally. It demands that we care
for the sick poor. . . .
By pursuing the same course, two small wards, one for each sex, could be
opened in the San Francisco Hospital, and this most important work of the care
for and observation of mental cases be properly undertaken; then, when its
utility had been proved beyond doubt, a separate psychopathic building could be
There are in many homes in San Francisco people who are mentally affected,
whose friends and relatives prefer to bear the pain and burden of caring for them
in secret rather than go through the repellent process of swearing out a warrant
and having a commitment to a State asylum follow. ...
A period of observation would enable the trained psychiatrist to decide what
was best for the patient, and in many cases start the sufferer on the road to
recovery rather than to the asylum.
That this latter statement may not be deemed presumptuous, coming from
a non-medical man, I state that an eminent psychiatrist in this city, in charge
of the psychopathic ward of one of our best private hospitals, said as recently
as two days ago:
"The number of cases that are committed to our State asylums for the insane
that Avould, under proper treatment, be restored to sanity, is colossal."
The California Society for Mental Hygiene represents the expert pro-
fessional, and a large sympathetic lay opinion and interest in this field,
but without specific local program and support, a beginning can hardly
be said to have been made in humane, just, intelligent, scientific salvaging
or protection of the sick, and education or prevention among the well in
the realm of mental, nervous and behavior disorders which cause so large
a proportion of our delinquency, dependency and family distress.
Under the circumstances, it seemed best to obtain a body of opinion
by conference with those who had given close attention to the subject, and
the following statement is offered with the entire endorsement of the
The following organizations were represented at the conference : Cali-
fornia Society of Mental Hygiene ; California State Medical Society, Neuro-
psychiatric Section San Francisco County Medical Society; State Board
of Corrections and Charities; San Francisco Board of Health; Juvenile
Protective Association; Criminological Institute of San Francisco; San
Services for Health and Its Protection 19
Francisco Neurological Society ; University of California ; Stanford Uni-
versity; San Francisco Hospital; St. Francis Hospital.
Their report follows :
HOSPITAL BElD SERVICES
We find that there are three main general hospitals in San Francisco in
which the need of beds for mental cases is especially acute, viz., the University
of California, Stanford University, and San Francisco Hospital..
It is estimated that the minimum need of beds in these hospitals at the
present time is as follows:
University of California — Fifteen for diagnostic purposes and 25 for treat-
ment, or a total of 40 beds.
Stanford University — Ten for diagnostic purposes and 25 for treatment, or
a total of 35 beds.
San Francisco Hospital — A total of 50 beds, the capacity of the two wards
now available and equipped, but without personnel, and meeting the very urgent
recognized need of care for acute committable mental cases in this municipality.
We find that Mount Zion Hospital, St. Luke's Hospital, and Franklin Hos-
pital are caring for a certain number of mental cases on a pay basis, but do not
feel that they could widen the range of their services in this respect.
With reference to out-patient clinics, we find that there are only two clinics
daily available, viz., University of California and Stanford, and that there are
four at fairly frequent intervals, viz., at Mount Zion, St. Luke's, Polyclinic, and
Mary's Help Hospitals.
We feel that these should be developed further, rather than add new clinics
at the present time. In each case we find that the out-patient services are woe-
fully inadequate; patients wander from one clinic to another; there is very little
contact with the home conditions or attempts to modify the same, and in each
case this seems to be due to a lack of personnel, and not to the lack of vision
or reasonable desires of the respective clinics.
We feel very strongly that in the two main clinics, viz., University of Cali-
fornia and Stanford, there should be in each one specially trained neuro-psychia-
tric social service worker, one of the usual social service workers, one recording
stenographer-clerk, and one psychologist of the standard of the American Medi-
cal Psychological Association. The relationship of psychiatric cases with courts,
social service organizations and families is much wider than in any other type
of medical case, and in each instance, we find that psychiatric service is inade-
quately equipped and suffers partly because it is a subdivision of another service.
REQUIREMENTS OF SCHOOL CHILDREN
We find, according to the last census, that there are 85,000 school children
in San Francisco.
That there has never been a systematic examination of these children from
a neuro-psychiatric point of view.
That there are at present one ungraded school and 18 classes for ungraded
children in other schools, but that the waiting list of this sort is probably twice
the number of those at present cared for.
20 Hospitai, and Health Survey
We believe that the beginnings of juvenile delinquency are found among
these children, and that the most successful preventive measures can be taken
at this point. Some desultory work is being done as becomes possible at the
University of California to meet conditions in certain specified schools, but
this inspection is not yet completed, and in no sense gives an adequate idea of
the situation in all of the schools.
We are, therefore, very strongly of the opinion that an adequate psycho-
logical and psychiatric medical inspection of these schools is very much needed,
and that in San Francisco this would necessarily involve the use of full time
paid psychiatric and psychological personnel and such social sendee workers
and clerks as are requisite.
EMERGENCY COMMITMENT LAW NEEDED
There is in California at present a voluntary commitment law, which is
entirely satisfactory. There is, however, no emergency commitment law, and
we regret very much that it is impossible to make use of the State Hospital
service unless the patient is willing to go there voluntarily. In this connection,
however, we are strongly of the opinion that the mental hygiene efforts referred
to above would make possible the parole of a great many cases from, the State
hospitals who are now retained there because of the impossibility of finding any
agency to supervise them outside of the State hospitals.
Judging from the experience in other states, we are of the opinion that
the saving to the taxpayer in removing these patients from State hospitals
would compensate for a large part of the increased expense in developing a
mental hygiene service for San Francisco.
In the various northern State hospitals, there are at present patients from
San Francisco to the extent of from one-third to two-thirds of the admissions
to the State hospitals, that is, some hospitals receiving one-third and some
two-thirds of all their patients from the population of San Francisco.
DEMONSTRATION CLINIC FOR DELINQUENT CHILDREN
While we find a great deal of interest in San Francisco in the abstract
questions of mental hygiene, we feel that it is very essential that there should be
a demonstration clinic for a period of at least six months, which would show the
actual conditions in San Francisco.
We believe that the question of juvenile delinquency is very closely as-
sociated with the question of the survey of school children in San Francisco,
and we see no reason why the conditions should be any better in San Francisco
than in Cincinnati, St. Louis, Cleveland and elsewhere.
According to the reports from these places, we may expect that San
Francisco will find that two-thirds of her problems of delinquency and dependency
have to do with mental hygiene. It is evident, therefore, that a demonstration of
San Francisco's needs would lead to more effective effort than we have witnessed
in the past.
We beg to submit that San Francisco's needs are urgent and greater than
those of many cities of which we have knowledge.
This restrained, moderate and well-considered statement of fact and
recommendation suggests rather than discloses the truly astonishing neglect
of the most pitiful, as well as the most hopeful, of those who need medical
and social care.
The Survey is deeply indebted to the authors of the foregoing state-
ment of the situation.
Services for Heai/th and Its Protection 21
There were reported to the Department of Health in 1922, cases,
deaths and isolation in hospitals of syphilis and gonorrhea as follows :
Reported Deaths Admissions
Syphilis 1011 82 42
Gonorrhea 935 13
1946 82 55
Of course, no such statement is to be accepted for a moment as repre-
senting even an approximation of the true situation.
The cases reported are with rare exceptions those applying for
treatment at public dispensaries and hospitals. There are probably at
least fifty times as many cases, not all in the communicable stages of the
diseases, of syphilis and gonorrhea at any one time in the city of San
Francisco. A good reporting of these diseases would be inferred if noti-
fication of 5400 cases, or 1000 for each 100,000 of the population, was
made to the Health Department.
It is estimated that at least 500 cases for each 100,000 of the popula-
tion (2700) will require treatment through public agencies in a year.
The report of deaths deals only with those directly and obviously due
to the effects of syphilis and does not include deaths from paresis, locomotor
ataxia, luetic disease of heart, arteries, or other systems and organs.
The report of hospitalization represents only those patients admitted
to the San Francisco Hospital for detention purposes, as venereal diseases
are not admitted under these diagnoses to any other hospitals in the city.
Since 1906 there have been various groups, medical, social, official and
lay, which have for one phase or another of the problems of venereal
disease, organized, started reforms and then ceased to function, until at
present there is no body of informed opinion prepared to influence public
or private agencies in the prevention and control of syphilis and gonorrhea.
Studies were made of hospital expenditures and days of care for
venereal diseases as long ago as 1910. For a while a municipal clinic cared
for the suspected common prostitutes from the "cribs" of the old "Barbary
Coast/' Then there was a period when attempts at sex education held the
public interest. The elaborate and largely effective . federal effort during
the war was followed by a period of laxity in public interest and official
action for protection or treatment.
Outside of the activities of the venereal disease divisions of the
State and City Health Departments and the usual diagnostic and treatment
services of several dispensaries, it is fair to say that nothing of a con-
structive, educational, recreational, social or legal character is being done
in San Francisco. In spite of the efforts of several groups in the past,
22 Hospital and Heai/th Survey
many of which were productive of valuable but temporary results, nothing
is now under way or apparently contemplated in the shape of professional
leadership which can be relied upon to make headway against public in-
ertia, indifference, and ignorance of this group of prevalent insidious and
highly communicable and preventable diseases.
IVrhaps first in importance is the incompleteness of reporting by the
physicians of the city as required by law. A judicious mixture of educa-
tion, of public spirit, of official pressure through the San Francisco Medical
Society, the hospitals, the Health Officer and the State Department of
Health might be expected to correct this. With the medical profession
indifferent and resistant to reasonable requirements of the health depart-
ment, education of the public will certainly lag.
There are provided for the indigent sick only two clinics for venereal
diseases, in the morning and evening at the University of California
Hospital and in the evening at the Lane and Stanford University Hospital.
These services are of a high grade, but represent only twenty-three dis-
pensary hours a week and do not include social or follow-up supervision
of active cases sufficient to keep track of patients until they are cured.
At the city prison and at the central office of the Department of Health
examining and treatment stations are maintained. Co-operation among
the departments of the city administration for the discovery and isolation
of sex offenders who are infected is reasonably effective.
In San Francisco as in most other cities the ancient prejudice, really
an expression of so-called "moral" rather than sanitary or medical opinion,
against men, women or children suffering from venereal disease whether
acquired "innocently" or through some a-social practices, results in the ex-
clusion from the benefit of hospital care of these sick and suffering patients.
This self-righteousness of hospital administrations bears heavily upon
patients needing bed care during some period of the course of their disease
and contributes to the neglect of intensive and adequate treatment which
permits a prolonged period of communicability of many patients.
Beds in every general hospital, and in certain types of cases beds in
general medical or surgical wards for men and women should be made
available for cases of syphilis and gonorrhea in the communicable stages.
Hospital technique under all but the crudest of conditions is quite adequate
to prevent the transmission of infection to other patients.
If there should be established a Health Council, representative of all
the interests of public bodies in health, it w r ould seem essential that a sub-
committee or functional group be organized within its members to assume
responsibility for studying the venereal disease situation in San Francisco,
to reassemble the many scattered elements of interest of the groups
formerly active in this field, to prepare a program of practical nature
embracing the preventive resources of social, educational, recreational and
sanitary character as well as the facilities required for treatment and re-
habilitation of the sick, and then to develop public opinion and resources
to put plans into effect.
Services for Health and Its Protection 23
With the great reduction in the death rate from tuberculosis to 100
per 100,000 of the population, attention has been drawn more than ever to
the heavy loss of life from what is now the leading cause of death — organic
diseases of the heart. For every 100,000 of the people of San Francisco,
258 died in 1922 from heart diseases, while 151 died of cancer, 112 of
violence and 100 of tuberculosis. As has been suggested in Section I, the
relatively high proportion of persons of the later decades of life is in part
responsible for San Francisco's particularly high death rate from heart
diseases and cancer.
It is but natural that the leading cause of human deaths should develop
a demand for prevention or an explanation of our limitation or helplessness
in the matter. It is well known that cardiac disease of children may be
due to neglect of infections of tonsils and teeth, of convalescence after
rheumatic, choreic, and other infectious fevers, and that syphilis is the
original infection which leads to many an adult death from aneurysm and
other diseases of the heart and arteries.
San Francisco has shared, like many of the larger cities of the country,
in providing special clinics for the diagnosis and supervision of heart
patients, particularly children who can be spared much subsequent dis-
ability by medical guidance, home instruction, vocational training and suit-
able placement in work. Cardiac clinics are in operation at the University
of California, Lane and Stanford University, Mount Zion and Children's
Hospitals. No educational effort is under way to teach the special need
of avoiding exposure to infection where infection of the heart has been
Heart patients, more than any other group, except perhaps the tuber-
culous and mental patients, need periods of convalescent care under favor-
able country conditions. There are in the immediate vicinity of New York,
more than 300 beds for such patients (not chronic invalids). San Fran-
cisco is about to have its first facility of this character, made available for
children at the Stanford Convalescent Home at Palo Alto.
In New York City, as many cases of heart disease are in attendance
at the forty cardiac clinics as attend the thirty-one tuberculosis clinics and
still the need of service and possibilities of protection and prevention
continue to expand.
Those who already see the importance of this problem from the social
as well as the medical point of view might well associate themselves under
the auspices of a Health Council to permit a crystallization of opinion in
support of some such program as is now being developed in Boston, Phila-
delphia, St. Louis, Chicago and New York.
We are only in the infancy of our efforts to make progress against the
high "mortality from cancer. The more careful studies of recent years
make it appear probable that cancer is not increasing as a cause of death,
except to the extent that the average duration of life has been extended
24 Hospital and Heai/th Survey
so that many more people reach the decades of life in which cancer com-
monly occurs, or because in one or other community, owing to climatic
or economic reasons, there is an unusual preponderance of persons of
forty years of age and over, among whom deaths from cancer are sure
to occur in larger numbers than in populations of lower average ages.
Furthermore, there is accumulating definite evidence to the effect that in
respect to certain cancers of the surface or orifices of the body, reduction
of death rates has been accomplished by the application of the same type of
resources which have been effective in other diseases such as tuberculosis,
namely, early accurate diagnosis and appropriate treatment by removal or
destruction of the localized disease process. Cancer is properly considered
a preventable cause of death not only on account of the successes of sur-
gery, but from the fact that we now know a great many of the causes of
origin of cancer due to repeated local injury, irritation, and damage to tis-
sues of the body by occupation, habits and infectious processes.
San Francisco has shared with the rest of the country in the educa-
tional efforts of the surgeons of the city who have given liberally of
time to teach the public all that is proved of the causes and means of con-
trol or cure of cancer. These educational services have been periodic and
have usually been a part of national efforts initiated by the parent society
of which leading surgeons of San Francisco are the regional representatives.
San Francisco, Sacramento and Los Angeles lead the cities of the
United States in the rate of cancer mortality. It is becoming of increasing
importance to all parts of the country that each community should
study its own situation and thereby contribute specific facts not only as a
guide for its local educational and preventive efforts, but for the benefit
of the whole nation. While in the past, most of the analysis of the cancer
situation, as was the case twenty-five years ago in the tuberculosis field,
was through study of deaths and death rates, it is obvious that progress
can hardly be made further without records of the incidence of the condi-
tion, the immediate causes and the conduct of those afflicted, with special
reference to the promptness of diagnosis and the adequacy of the treatment
Reporting of the diagnosis of cancer to the Department of Health,
without implying* that the public authorities should have any jurisdiction
over the patient or his treatment, would make possible a body of informa-
tion of the utmost importance.
Education of the public in the preventable and curable aspects of
cancer and in the necessity of personal alertness and attention to warning
signs and symptoms of the early stages of cancer, might properly be
undertaken as part of any broad program of public education in health
and its protection.
From the point of view of the sick cancer patient, San Francisco has
not met her obligations, or shall we say, her opportunities for service.
Hospital beds for inoperable cases of cancer are almost unobtainable,
and especially for the poor. Definite provision at the San Francisco and
other general hospitals might be made in the medical or surgical wards for
cancer patients for whom home care is impracticable.
Services for Health and Its Protection 25
When there is a visiting nurse service throughout the city, it will
probably be found that large numbers of cancer patients are in need of
attention whose miserable state at present is only relieved by death.
Hospital care in homes for incurable disease is a humane service which
would meet the needs of those for whom the general hospitals or home
nursing are inappropriate or impractiable.
It would seem that the problem of cancer is worthy of separate and
special consideration by a sub-committee of such a Health Council as is
PERIODIC HEALTH EXAMINATIONS
It will have been noticed in the reading of the preceding text dealing
with the larger problems of preventive medicine that the essential for pro-
tective as well as for curative medical service is a thorough medical
examination. To an increasing degree those planning well-proportioned
campaigns for disease prevention at all ages, realize the dependence of
every phase of the work upon examination of apparently healthy persons,
at such intervals as will secure a continuance of health, and give a sound
basis for individual advice in avoiding such errors of habit, conduct, or
exposure to disease, or the effects of advancing years, as commonly inter-
fere with health.
In addition to the emphasis necessarily placed upon such health ex-
aminations by those particularly interested in tuberculosis, child hygiene,
heart diseases, etc., a truly impressive contribution to the health of the
community would result from the adoption of a policy on the part of
every institution and agency, public or private, co-operating under the
Council of Social Agencies, or the Community Chest, whereby every mem-
ber of the staffs and directing bodies should have an annual health exami-
nation, preferably by their own family physician. Such an example would
not only add materially to the health assets in terms of years of fruitful,
happy work, and enjoyment of life of those engaged in community service
of many kinds, but it would go far to develop the habit of such a pre-
caution throughout the population.
Such a personal annual health stock-taking at the hands of a competent
physician is the least that any individual can do to contribute to his own
and the community's health.
In the realm of social and relief work, intelligent, constructive family
case service cannot be given unless there is a thorough medical examination
provided for each member of the family before final decision is reached
regarding the provision for individual or family rehabilitation.
The importance of medical health examinations has recently received
especial endorsement from the American Medical Association and from the
member associations of the National Health Council. The necessity of a
public facility for health examinations of dispensary clientele, and for the
teaching of medical students, has been recognized by the University of
California Medical School in the proposal to establish a health clinic at
the University of California Hospital dispensary in the immediate future.
26 Hospital, and Heai/th Survey
A SAN FRANCISCO HEALTH COUNCIL
The Committee on Hospitals and Health Agencies of the Council of
Social and Health Agencies of San Francisco is charged with the same
kind of double function which has been criticized above in the considera-
tion oi the Board of Health and its direction of the San Francisco Hos-
pital and the Department of Public Health.
It will appear reasonably clear from a reading of the facts presented in
Section III that the care of the sick by hospitals and dispensaries is sus-
ceptible of great improvement, from the point of view of quality, quantity
and costs. There have been presented above brief discussions of a few r
of the more important public health problems of San Francisco, with here
and there a suggestion that study and planning must be undertaken seri-
ously if accomplishment is to keep pace with the established facts of
science and the reasonable desires of good citizenship.
These two truly great fields of human endeavor, namely, to give the
best of care to the sick, and to develop and protect health, though closely
bordering upon each other at many points, are so different in their content
that they require quite separate and distinct groups for their analysis and
If the Committee on Hospitals and Health Agencies should resolve
itself into two groups, one possibly called a Hospital Council and serving
functions described in some detail in Section III, the other a Health
Council devoted to the study and development of such projects as have
been dealt with above in Section II, both types of public service would
receive much needed stimulation with a promptness not otherwise likely.
If such a group or council, devoted to the health problems of the com-
munity, were created from among the considerable number of competent
and public spirited men and women interested and professionally trained
in one or more of the aspects of health protection, who are now available
in San Francisco, they would require a permanent paid secretary to be
their executive officer, not simply to carry on office correspondence, but
to assemble facts, make original inquiries into the work of health agencies
and prepare matters for the consideration of the various sub-committees
which would be held responsible for the formulation of programs or
Sub-committees would be called for and appointed from those with-
out as well as w T ithin the membership of the Health Council, according
to the changing needs from year to year, but in all probability for a long
time to come there will be a use for standing committees devoted to such
leading subjects as have already enlisted much public support. There might
well be committees on : Public Health Education, Health Department Prac-
tice, Child Hygiene, Mental Hygiene, Cancer, Heart Disease, Social
Hygiene and Visiting Nursing.
The San Francisco Tuberculosis Association would be to all intents
and purposes the committee on tuberculosis of such a Health Council.
Services for the Sick
While care of the sick in bed in hospitals, or the walking patient at
the dispensary, may have expressed the full conception of service in this
field in the past, at present the vision of curative and preventive medicine
calls for other institutions better suited to the needs of certain groups of
invalids, and for the collaboration of the professions trained to teach health
and to complete medical care by social assistance.
The best that can be provided for the patient with ample means, by
the attention and continuous guardianship of the private practitioner of
medicine, is more and more found to be practicable for the wage earner
and the dependent family, through the correlation of services offered by
public or privately supported agencies.
Without attempting to outline the entire range of institutions and
organizations which may at one time or another be called upon to
assist in the process of re-establishing the sick in health of body and mind,
it has been considered by this Survey that in addition to Hospitals and
Dispensaries, recognized as public services of much importance to the
safety and comfort of the community, the following auxiliary or inter-
locking agencies are similarly essential : The Visiting, Public Health or
District Nurse Association, Medical Social Service, Convalescent Homes,
and Homes for Incurable or Chronic Invalids.
All of these agencies, through the suitable co-operation of which the
sick are helped to regain health, or to prolong life without unnecessary
suffering or disability, are so intimately related to each other in any com-
plete plan for modern service to the sick, that the adequacy of each in a
community must be studied before recommendations can be offered for
changes or extension of any of the others.
HOSPITAL PROVISIONS AND COMMUNITY NEEDS
In studying the particular place filled by a group of hospitals, it is
necessary to picture them in relation to the total hospital facilities and
to appraise their contributions in connection with the generally accepted
standards of hospital service.
San Francisco has nineteen hospitals exclusive of those maintained
for the convalescent, insane, incurable, aged and infirm. As in other
cities, these represent two general types of institutions: (a) those hospitals
which have been gradually built up by voluntary effort or public taxes
for the community as a whole, and (b) proprietary institutions which,
growing up spontaneously as business enterprises, furnish service for the
sick comparable to that of the private school in the field of education
28 Hospital and Health Survey
which serves only special social, religious or economic groups or a clientele
limited by trade, occupation, race, etc.
The following table indicates the hospital accommodations under public
and private control, and of the latter, those which accept funds as charitable
institutions, and those which are maintained as commercial enterprises:
Hospital Facilities of San Francisco*
San Francisco Hospital (supported by City Taxes) 893
University of California Hospital (supported by State Taxes) 282 1175
Privately Controlled Institutions
Accepting Funds as Charitable Institutions —
Children's Hospital 275
Franklin Hospital 214
French Hospital 200
Lane and Stanford Hospital 314
Mary's Help Hospital 147
Mount Zion Hospital 150
Shriner's Hospital 50
St. Joseph's Hospital 202
St. Luke's Hospital 141
St. Mary's Hospital 166 1859
Maintained as Commercial Enterprises —
Dante Sanatorium 65
Florence N. Ward Hospital , 50
Hahnemann Hospital 112
Morton Hospital 100
Southern Pacific Hospital 250
St. Francis Hospital 325
Union Plant and Alameda Works Hospital
(Bethlehem Shipbuilding Corporation) 24 926
None of the privately supported hospitals accepting voluntary contribu-
tions as charitable undertakings, receive public funds, there being in San
Francisco no system of public subsidy for the care of the indigent sick in
other hospitals than those maintained by taxation. With the exception of
two institutions, which have not applied for appropriations from the Com-
munity Chest, all of the private charitable hospitals receive Chest support.
The two exceptions in question are the Shriners' Hospital, the main public
activity of the Sacred Order of the Mystic Shrine, furnishing free hospital
care to children from the extreme Western States, suffering from ortho-
pedic disabilities, and St. Joseph's Hospital, which is conducted by the
Sisters of St. Joseph, and. which, furnishing care chiefly to full-pay
*The following for various reasons are not included in the general hospital facilities
of the community: Polyclinic Hospital, 12 beds; Molony's Hospital, 10 beds; and St.
Peter's Hospital, 5 beds.
Services for the Sick
patients, has not as yet requested funds to meet the care of the free and
part-pay service furnished.
The nineteen hospitals listed include those for both general and
special cases of an acute and chronic nature, the special institutions re-
ceiving only such patients as are suffering from a particular type of
disease or disability. Since certain of the facilities are thus available only
for special conditions, the adequacy of the hospital accommodations of
the city is dependent upon the distribution of the 3960 beds, according to
the various medical services. These facts are shown in the following
Distribution of Hospital Beds by Medical Service
CJ r»n f^y
San Francisco 893
California. . , 282
• • • • • •
Totals ....1175 805 260
57 127 -
Privately Controlled Institutions
Accepting Funds as Charitable Institutions —
Children's . . .
• • *
• « a
• • •
Lane and Stan-
ford Univ. ..
Mary's Help .
• • •
Mount Zion . .
St. Joseph's ..
St. Luke's . . .
• • •
St. Mary's . . .
• • •
. . .
• • •
Totals 1859 1833 146
Maintained as Commercial Enterprises —
St. Francis ,
So. Pacific .
Totals 926 926
Grand Tot'ls 3960 3564 416
• • •
• • •
• • •
• • •
. . .
. . .
• ■ •
♦This total includes 114 cribs for new-born infants, as new-born are assigned to the
pediatric services in a few of the hospitals.
30 Hospital and Health Survey
Experience indicates that a provision of five general hospital beds for
each thousand of population is needed to afford adequate facilities for
the hospitalization of general medical and surgical conditions, maternity
patients and children. In addition, there are needed, for the acute com-
municable diseases, five beds for each ten thousand of population,, and
for the tuberculous, as many beds as there are deaths in the year from
It has been found in the larger cities of the country that the ratio of
live beds for general medical and surgical patients per thousand of the
population should include five beds per 10,000 persons for children, and
forty-five beds per 100,000 to hospitalize 30 per cent of the maternity
Based upon the foregoing, San Francisco, with a population of 540,000
should have, as a minimum, 2700 general hospital beds, 270 beds for acute
communicable diseases, and 500 beds for tuberculosis.
It is evident that, with 3564 general hospital beds available, affording
6.6 beds per thousand of population, there are sufficient facilities to meet
this minimum of the city's needs.
In considering the question of ratio of beds to population, however, it
should be borne in mind that the hospitals serve a much larger area than
the general metropolitan district. Due to the city's prominence as the lead-
ing medical center of the Pacific Coast, patients come from distant sec-
tions of the State and from outside of the State, to take advantage of the
superior facilities available for diagnosis and treatment. For example, the
University of California receives patients from the entire State, several
other of the institutions — the Southern Pacific Hospital and the Shriners'
Hospital — accepting patients from neighboring States as well.
The extent to which non-residents use the hospitals was indicated by
the Survey's analysis of the places of residence of some 6000 patients
admitted to ten of the hospitals (representing 70 per cent of the total
hospital facilities) during November, 1922, and January, 1923. As this
study showed that 16 per cent of the patients were non-residents of San
Francisco, it is believed that the true minimum number of general beds
should be not less than 2970, that is, at least 10 per cent more than the
minimum for the city's population alone.
The birth rate of the population of San Francisco is not over 16 per
thousand of the population, and the practice of the people of San Fran-
cisco is to hospitalize at least 65 per cent of their maternity patients — the
percentage hospitalized increasing steadily in recent years. It is suitable,
therefore, in determining the number of beds needed for maternity care
under the general heading of beds for medical and surgical patients, to
alter estimates appropriate for industrial cities in the Eastern United
States, where the birth rate is 20 per thousand of the population or over,
and where experience shows that rarely more than 30 1 per cent of mater-
nity patients are cared for in hospitals.
Instead, therefore, of providing for an estimated 30 per cent of the
Services for the Sick 31
8557 births reported in the twelve months ending June 1, 1923 — 2567 — by-
setting aside 128 beds, that is, one bed for each twenty such hospital
patients a year, San Francisco should provide hospital beds for not less
than 75 per cent of the births, or 320 beds. As this is 77 beds more than
the number required to hospitalize 30 per cent of the maternity patients
on the population basis (243 beds), the total minimum desirable beds is
thus raised from 2970 to 3047.
Based upon these accepted ratios we have thus, all told, a theoretical
need in San Francisco for the 540,000 population and non-residents, as
1 — General Medical and Surgical Conditions 3047
(a) Children 270
(b) Maternity 320
(c) Others 2457
2 — Acute Communicable Diseases 270
3 — Tuberculosis 500
By consulting the table of hospital facilities on page 29, it will be seen
that the accommodations available for the foregoing groups are:
1 — General Medical and Surgical Conditions 3564
(a) Children 135*
(b) Maternity : 221
( c ) Others 3208
2 — Acute Communicable Diseases 146
3 — Tuberculosis 250
Comparison of the available and the theoretical facilities indicates that,
although for the general medical and surgical conditions there are over
500 more general beds than the suggested minimum, the facilities for chil-
dren are one-half and those for maternity patients one-third less than the
The provisions for the acute communicable disease, while 124 beds
less than the theoretical requirement, appear adequate, due to the low
hospitalization of such conditions. In view of the foregoing, and as there
are 150 beds available in case of need in the old Isolation Hospital, there
is no apparent present shortage of facilities for this patient group.
The facilities for the tuberculous show a serious shortage. If we
include the preventoria accepting active tuberculosis cases, there still
remains a shortage of 150 beds for this important specialty, as presented
in detail earlier in the report.
To sum up — Compared with the experience of other cities, San Fran-
cisco has :
(a) Ample beds for the general medical and surgical services, although
there is an insufficient number of beds specifically equipped and set aside
* Exclusive of 114 beds for new-born infants.
32 Hospital and Health Survey
for the care of children, and an insufficient number assigned to maternity
(M Sufficient facilities for communicable diseases in view of the lim-
ited use of hospitals for the isolation of the common communicable dis-
(c) Need for from 150 to 250 additional beds for tuberculosis.
The hospitals receiving the more special attention of the Survey
included the nine institutions which are receiving or have applied for funds
from the Community Chest and the San Francisco Hospital, which was
studied only in so far as its activities relate to the hospital and health
problems studied. The ten hospitals are :
Hospitals Included in Survey
Public Institutions —
San Francisco Hospital . 893
University of California Hospital 282 1175
Privately Controlled Institutions —
Children's Hospital . 275
Franklin Hospital 214
French Hospital 200
Lane and Stanford University Hospital 314
Mary's Help Hospital 147
Mount Zion Hospital ' 150
St. Luke's Hospital 141
St. Mary's Hospital ' 166 1607
The importance of these institutions as major community activities is
indicated by the fact that, combined, they constitute 70 per cent of the total
hospital facilities of the city. As a group, during 1922, they cared for
approximately 50,000 patients and furnished 630,000 days of treatment. In
addition those that maintain dispensary departments furnish 87 per cent of
the total hours of dispensary service of the city, and, during 1922, received
approximately 252,000 visits — 90 per cent of the total number of visits.
The location of these institutions, together with the volume of service
rendered to bed patients and out patients, is shown in Map 1 on the oppo-
As medical agencies, they provide 94 per cent of the facilities defi-
nitely assigned to the various medical services, there being practically no
formal distribution of beds in the other hospitals of the city. The magni-
N V 3 3 O
J I J I J V cl
34 Hospital and Health Survey
tudc of their activities is reflected in their finances, as combined, they rep-
resent a total estimated investment of over $11,000,000, with annual expen-
ditures amounting* to over $3,700,000.
Although eight of the hospitals are privately controlled, their large
contributions to the community's welfare indicate that they occupy a posi-
tion similar to that of public service corporations — organizations which,
though privately owned and directed, minister to the common welfare by
supplying community needs. The extent to which they supplement tax-
supported facilities is shown in the fact that, as a unit, they furnished 16
per cent of the free bed care during 1922, and 75 per cent of the bed care
of patients who paid only part of the cost of hospital service.
Their relation to the Community Chest may be briefly stated:
Of the two hospitals supported by taxes, the San Francisco has made
no application for funds collected by the Chest, the University of Cali-
fornia, through its Auxiliary, concerned with out-patient and social service
activities, receiving $6000 for 1923. In addition, the last-named institution
has applied directly for funds for bed care.
Six of the privately supported institutions receive Chest funds, one of
them. Lane and Stanford University Hospital, receiving funds through the
Stanford Clinics Auxiliary and San Francisco Maternity* the organization
maintaining the hospital's Social Service Department. In addition, appli-
cations for participation in Chest funds are pending for the French, Lane
and Stanford University, and St. Mary's Hospitals,
The amounts allocated to the several hospitals for 1923, in each
instance corresponding to the amount obtained from charitable sources in
recent years, are as follows :
Children's Hospital , . $ 87,000
Franklin Hospital 15,000
Mary's Help Hospital 12,000
Mount Zion Hospital 85,000
St. Luke's Hospital.... _ 20,000
Stanford Clinic's Auxiliary and San Francisco Maternity 12,227
University of California Hospital Auxiliary 6,000
ORGANIZATION AND ADMINISTRATION
To accomplish their common end — "to care for the sick," "to aid the
sick and suffering," "to give medical care and comfort to the sick," "to
assist in medical education," "to train nurses," etc.— various types of gov-
erning boards have been set up with more or less well-defined organiza-
tions, committee activities, and administrative policies.
Of the two publicly supported institutions, the San Francisco Hospital
is directed by the Board of Health, a combined lay and professional board
Services for the Sick 35
of seven men serving without remuneration. The Board meets weekly, and
has finance, hospital, and building committees with definite responsibilities,
and receives frequent and detailed reports of certain of the institution's
activities. As it also directs all of the other activities of the Board of
Health, it is not exclusively the managing board of the hospital.
Experience has demonstrated that the operation of a hospital is best
served by a board whose sole function is the direction of the institution.
The manifold responsibilities carried by the Board of Health and the
diversified activities which it directs suggest a need for a specially
appointed group, such as a board of trustees, to which it could delegate
the responsibility of the direction of so important an undertaking as the
hospital, the largest in the city and caring for the greatest number of
patients. Other cities are adopting this method of meeting the special
needs of municipal hospitals. For example, the Cleveland Hospital Council
has recently made formal recommendations to the Cleveland City Council,
urging the appointment of a board of trustees for the Cleveland City
The University of California Hospital, directed by the Board of Re-
gents of the university, is likewise but one of many activities receiving
the attention of the regents. The committees of the Board, comprising
Agriculture, Conference with Faculty, Educational Relations, Endowments,
Engineering, Executive, Finance, Grounds and Buildings, Jurisprudence,
Letters and Science, Library, Research and Publications, Lick Observatory,
University of California Medical School, Southern Branch of the Univer-
sity of California and Scripps Institution for Biological Research, and Wil-
merding School Committees, makes no special provision for the direction
of the hospital's affairs.
It is the general sentiment in present day hospital operation that the
lack of a directing group, whose sole function is the operation of a hos-
pital, deprives both the staff and the hospital administration of a highly
desirable contact with the responsible, policy-forming body.
The hospital is an institutional member of the American Hospital
Association, and publishes no annual report.
The Hahnemann Hospital (not included among the hospitals studied
in detail in this Survey) , formerly the Homeopathic Hospital and acquired
by the university in recent years, is maintained by the regents as a general
hospital for private and industrial cases. The present policy, which appears
to take small account of the medical standards at this institution, is judged
unsuitable and unworthy of so responsible a board as the regents of the
university. The hospital is more like a stepchild than a member of the
university family, as regards its medical standards and administrative
Brief mention may be made of the directing organization of the eight
privately controlled institutions :
Children's Hospital — The Children's Hospital, incorporated in 1875,
for the exclusive care of sick women and children, the education of women
36 Hospital and Heai/th Survey
physicians, and the training of nurses, has a Board of Trustees consisting
of five men which meets monthly and is concerned only with the finances
of the institution. The direction of the hospital is centered in a Board of
Women Managers of thirty, which meets monthly with an average attend-
ance of two-thirds of its membership. The committees are Executive,
Finance, Joint, Conference, Admissions, Social Service, Training School,
Housekeeping, and Building. The reports considered by the Board of
Managers relate to all hospital departments and to all committee activities.
Although the committee organization of the board provides for committee
supervision of specific activities, it is evident that many committee func-
tions are administrative rather than directing, and that the personnel of
some committees is not sufficiently comprehensive.
The Conference Committee, a joint committee of the board and medi-
cal staff, is comparatively recent and in line with present-day methods of
establishing contact between directing and professional groups. At the
time the institution was visited, the board had not required of its staff the
usual monthly clinical conferences, nor was there any program for staff
review of the medical work of the hospital. The Training School and
Social Service Committees do not include all the advisable elements in their
membership, and there is no Dispensary Committee, although the hospital
operates a dispensary department.
The Board of Trustees has not so directed the hospital's finances that
budgetary methods are used or that a financial plan is in effect.
The board, conducting a notable service to the community and holding
large funds entrusted to its use for the care of the sick poor, has published
no annual report since 1918. The institution has no- national hospital
Franklin Hospital — The Franklin Hospital is maintained by the Ger-
man General Benevolent Society, an incorporated insurance association,
founded in 1854, to provide relief to men, women, and children of German
origin and to maintain a medical organization and hospital for the benefit
of its members. The activities of the Society are directed by a Board of
Directors which meets monthly, the hospital being supervised by a Hospital
Committee which meets bi-monthly. These two groups receive bi-monthly
reports of finances and the activities of the hospital and the Society. The
activities of an auxiliary committee composed of women are limited to the
relief of beneficiaries of the Society living in their homes. The board lacks
the indicated organization for the direction of hospital activities as the
usual committees such as executive, finance, training school, etc., have
not been established. The institution has no national hospital member-
ships. The annual report of hospital activities is contained in the Society's
report and consists of a rather complete financial statement, but only
brief statistical hospital material. The attending staff holds monthly clinical
meetings, but as the board does not require complete medical histories,
the review of the medical work is not complete.
French Hospital — The French Hospital, maintained by the French
Mutual Benefit Society, did not furnish the Survey with the needed infor-
Services for the Sick 37
mation regarding organization, administration, finances, etc., the only mate-
rial furnished relating to the number of patients and days of care for 1921
and 1922. The annual report of the Society indicates that the hospital,
founded in 1852, is maintained to furnish hospital care to medical and sur-
gical cases and to members of the mutual benefit association. The Society
is governed by an Administrative Council of fifteen, with the usual officers.
Details as to committee organization and function, hospital memberships,
etc., are not known. The Society's annual report does not segregate hos-
pital and Society income and expenditures, and presents only a meager
picture of the institution's activities.
Lane and Stanford University Hospital — Lane and Stanford Univer-
sity Hospital has been maintained by Leland Stanford Junior University
for a little over ten years as an incorporated department of the uni-
versity. The hospital's affairs are directed by a Clinical Committee com-
posed of four members of the Medical School faculty and the physician
superintendent of the institution. The committee meets monthly, has the
usual officers but no sub-committees, and receives complete and detailed
monthly reports. There are no auxiliary committees to the Clinical Com-
mittee, although the Stanford Clinic Auxiliary and San Francisco Mater-
nity, which maintains the Social Service Department, is in effect an aux-
iliary to the hospital's directing group.
As in the case of the two publicly supported hospitals, it is judged
that the best interests of this institution will be served by the establishment
of a lay board of trustees, which includes women members. The present
organization of the institution — the hospital conducted by one group, the
Out-Patient Department conducted by the Medical School and the Social
Service Department conducted by a group with no formal connection with
the hospital — provides separate direction and financial responsibility of
activities which are essentially administrative departmental units of the
The hospital has no national memberships. It publishes an interesting
and rather full annual report of hospital activities, exclusive of finances,
containing brief hospital statistics and analyses of use, and presentations
of the activities, needs and new objectives of most of the medical depart-
ments. The Stanford Clinics Auxiliary and San Francisco Maternity pub-
lishes a separate report of the work of the Social Service Department.
Mary's Help Hospital — Mary's Help Hospital, maintained by the Sis-
ters of Charity for the care of the sick poor, was incorporated thirty years
ago and is governed by a Board of Directors of six men which meets
monthly. The board has a president and secretary, and reviews financial
and statistical reports monthly, but functions without committees. The hos-
pital has no national hospital association memberships, and publishes no
Board organization of this limited character is no longer advocated in
Sisters' hospitals. Experience indicates that the interests of such hospitals
are better served by a board composed of lay men and women, members
of the Sisterhood conducting the hospital, and representatives of the Catho-
38 Hospital and Health Survey
lie clergy. Boards thus constituted are in successful operation in other
sections of the country, and have been found more effective in establishing
close contacts with the community than the smaller boards consisting of
men or Sisters only.
St Mary's Hospital — St. Mary's Hospital, founded in 1855 to care for
the sick, train nurses, and instruct students in medicine and surgery, is
conducted by the Sisters of Mercy and governed by a board of four Sisters
which meets monthly. The board has one committee, on finance, which
also meets monthly and submits financial reports. As previously men-
tioned, this type of organization is less effective in meeting community
health needs than the larger boards constituted as outlined. A women's
auxiliary recently organized to assist with a dispensary department, which
is in process of establishment, has as yet no definite functions.
The hospital is a member of the Catholic Hospital Association. No
annual report has been published since 1920.
Mount Zion Hospital — Mount Zion Hospital, incorporated in 1847,
primarily to serve the Jewish sick of the city, is governed by a Board of
Directors of seventeen which meets monthly, has the usual officers and
rather elaborate committee organizations, including Executive, Purchasing,
Kitchen, Diet-Kitchen, Laundry, Linen room, Dispensary, Social Service,
Finance, Pharmacy, Laboratory, X-ray, and Building and Grounds. Mem-
bers of the Ladies' Auxiliary, an unofficial group active in hospital work,
serve on many of the committees, in some instances constituting the entire
committee personnel. Committees meet monthly and submit reports to the
board through the Executive Committee. The committee organization sug-
gests that committees participate in administrative activities. Neither the
Committee on Nurses nor the Dispensary or Social Service Committees are
organized along the lines considered appropriate for their respective respon-
sibilities. An unusual committee is the Medical Conference Committee
composed of members of the staff, department heads and board officers,
which functions as a policy-making body in medical matters.
Members of the Ladies' Auxiliary also serve on many of the com-
mittees and as workers in the Social Service Department. The organiza-
tion as a whole suggests considerable activity both on the part of the board
and of the auxiliary. The institution has no national hospital association
memberships. A brief report of its activities is contained in the annual
report of the Federation of Jewish Charities.
St. Luke's Hospital — St. Luke's Hospital, founded in 1871 to care for
the sick, is governed by a Board of Directors of nine men and two women
which meets monthly and has, in addition to the usual board officers, a
combined treasurer and auditor. The committees of the board are : Execu-
tive, Investment, Training School, Social Service, and Dispensary. Of the
foregoing, the Executive Committee alone meets regularly. The other com-
mittees meet only on call, and do not include the personnel regarded as
advisable for effective board contact with hospital matters. The board does
not review^ the usual reports considered essential for the guidance of the
governing body of a hospital. Lacking reports of work done and a com-
Services for the Sick 39
mittee organization, there appears to be insufficient contact with hospital
affairs. The hospital is an institutional member of the American Hospital
Association and publishes a report annually, which, among other matters,
contains a complete financial statement and a less detailed statistical and
medical report. An auxiliary committee, called the Women's Board,
appears to function largely in rendering voluntary assistance.
So brief a summary of general policies does not depict the many indi-
vidual excellencies of organization and direction which exist, nor does it
convey a true impression of the instances of devoted and sympathetic
interest which characterize so much of the hospital service.
It is by no means uncommon in hospital affairs to find that the per-
sonal attention, good-will, and generous interest of board members are
hampered by poor organization, incomplete provisions for committee activi-
ties, and ineffective means for reviewing the results achieved.
An important development in the hospital world is that boards are
finding it advisable to effect changes in types of directing organization
which, though formerly satisfactory, are today unsuited to meet the
demands of modern hospital operation.
The directing groups of the ten hospitals would gain by a critical
self-analysis of the adequacy and suitability of their individual organiza-
tions for the administration of their respective trusts. It is clear that there
is need for a greater familiarity with many principles of board organiza-
tion, committee functions, public reports, etc., which are advocated by
leading hospital boards, administrators, and national hospital associations.
It is proper that attention be directed to the fact that the three most
prominent hospitals, both as to size and leadership — the San Francisco,
University of California, and Lane and Stanford University Hospitals —
lack boards so widely representative and thoroughly organized as to permit
the type of intensive study and direction of these great public utilities
which their complexity, cost, and importance demands.
. SERVICES RENDERED BY HOSPITALS
In learning the extent of the community service rendered by a group
of hospitals, we measure both individually and collectively, (a) the degree
to which the facilities are used, (b) the hospital care given to full-pay,
part-pay and free patient groups, (c) the medical services offered, and
(d) the areas and the sections of the population served.
The facts herewith presented relating to these factors of service for
the ten hospitals are based on the experience of 1921 and 1922, assembled
by the institutions for the Survey, the data collected on June 21, when a
census was taken of hospital patients, information collected at the hospitals,
opinions and facts furnished by physicians and medical and social agencies,
facts contained in published hospital reports, information collected by
visits to 160 patients discharged during the first three weeks of June, and
40 Hospital and Health Survey
an analysis of the places of residents of the 6542 patients admitted to the
hospitals during two representative months — November, 1922, and January,
(a) EXTENT OF USE OF HOSPITAL BEDS
The unit of measurement of hospital use is the care of one bed patient
for one day, the extent of use being indicated by the comparison of the
number of days' treatment furnished in a given period, with the number
of days' treatment available in the same period. For example, a hospital
of 100 beds with 36,500 days available yearly, if actually furnishing 30,000
days, uses 82 per cent of its potential facilities.
Hospital authorities estimate, allowing for renovations, repair of wards,
quarantine, and seasonal fluctuations in demand, that a general hospital
should use an average of 75 per cent of its available days of care for a
year as a whole, and that over 80 per cent of use should be expected
during the busier portions of the year.
A degree of use of less than 75 per cent is commonly due to one or
more factors, (a) overbuilding; that is, more hospital beds than are actually
needed, (b) unsuitable distribution of facilities for the several patient
groups, and (c) defective administration.
When an institution shows 85 per cent of use or more, it is generally
taken as an index that the demand for beds exceeds the supply, and that
the administration of the hospital is effective.
If each of the 2782 beds in the ten institutions was used every day
of the year, they could furnish a total of 1,005,210 days of care, but such
a performance would be impracticable in hospital administration and is
unknown in the experience of general hospitals for acute sickness.
The percentage of use during the past two years for the institutions as
a group, including the facilities for tuberculosis and acute communicable
diseases, was :
Use of Hospital Facilities, Including Tuberculosis and Communicable Diseases
1921 68% (685,778 days)
1922 71% (714,659 days)
The exact percentage of use of the general hospital beds is not known,
due to the fact that the San Francisco Hospital could not furnish the days
of treatment of the general hospital section apart from these data for the
120 beds in the communicable disease department.
The degree of use of the general hospital facilities for the past two
years, as given below, includes both the general and communicable disease
experience. The percentage of use of the 913,960 days of treatment thus
available was :
Use of Hospital Facilities, Tuberculosis Excluded
1921 67% (608,434 days)
1922 .69% (629,567 days)
Services for the Sick 41
During 1922 the hospitals cared for 51,811 patients, as follows:
Hospital Admissions — 1922
Public Institutions —
San Francisco Hospital 7993
University of California Hospital 4726 12,719 (25%)
Privately Controlled Institutions —
Children's Hospital 4873
Franklin Hospital 3838
French Hospital 2366
Lane and Stanford University Hospital 8933
Mary's Help Hospital 4071
Mount Zion Hospital 4657
St. Luke's Hospital 5960
St. Mary's Hospital 4394 39,092 (75%)
Total ." 51,811
The individual experience of the hospitals expressed in days of care,
presented in the following table and in Chart A, page 43, indicates the
total number of days of treatment available, the actual number of days of
treatment furnished, and the percentage of use these facts represent, for
each of the ten institutions.
42 Hospital and Health Survey
Degree of Use of Hospitals — 1922
Total Days Total Days Per Cent
Bed Care Bed Care of
Available Given Use
Public Institutions —
San Francisco r . . 234,695 158,027 67
University of California 92,710 61,049 66
Total 327,405 219,076 67
Privately Controlled Institutions —
Children's 100,375 60,128 60
Franklin 78,110 54,813 70
French 73,000 46,663 64
Lane and Stanford University 114,610 79,138 69
Mary's Help 53,655 34,379 64
Mount Zion 54,750 44,147 81
St. Luke's 51,465 39,457 76
St. Mary's 60,590 51,766 85
Total 586,555 410,491 69
Grand Total 913,960 629,567 69
As shown in the foregoing table, neither of the two tax-supported
hospitals, and but three of those receiving voluntary contributions — St.
Mary's, Mount Zion, and St. Luke's Hospitals — attained 75 per cent or
more of use ; the remaining five showing 60 to 70 per cent of use.
In order to ascertain the facts regarding possible periods of maximum
and minimum demand for hospital care, a further detailed analysis was
made of the percentage of use of the combined hospitals throughout a
twelve-month period. The result of this analysis, showing the percentage
of use by month for seven* hospitals is as follows :
Per Cent of Use of Combined Hospital Facilities by Month — 1922
October \ 68
Average for year, 69 per cent.
*The San Francisco, Mount Zion and St. Luke's Hospitals could not furnish these
• oj c
44 Hospital and Health Survey
This experience for the twelve-month period, also shown in Chart B,
page 45, while based on but 40 per cent of the city's hospital facilities, pre-
sents so slight a seasonal variation that it is probable that the experience
of the other institutions would be approximately the same. It is signifi-
cant that in no month of the twelve-month period did the seven hospitals,
as a group, show 75 per cent of use, the highest, 71 per cent, occurring
in but two months, February and March, and the lowest, 64 per cent, in
The degree to which the individual hospitals used their available num-
bers of days throughout 1922 is shown in the following table, which thus
indicates that, although as a group, the hospitals showed relatively slight
variation in the extent to which the available number of days were used
from month to month, there were considerable differences in the extent to
which individual institutions were used throughout the year:
Degree of Use of Individual Hospitals by Month — 1922 (Seven Hospitals)
Children's Franklin French Lane and Mary's St: Univer.
Stanford Help Mary's of
Per ct. Per ct. Per ct. Per ct. Per ct. Per ct. Per ct.
January 64 72 64 72 60 81 68
February 64 77 65 73 86 79 59
March 61 69 72 77 61 89 55
April 62 65 67 64 77 81 77
May 59 65 67 68 61 73 66
June 55 71 64 67 75 73 59
July 59 75 62 68 59 73 73
August 62 71 58 68 71 69 68
September 58 72 60 69 57 72 57
October 80 78 58 71 57 78 64
November 61 72 63 69 54 77 77
December 69 66 65 71 57 81 64
Thus, the percentage of use at the University of California Hospital
varied during the twelve-month period from 57 to 77 per cent. In only
two months, April and November, did the institution use 75 per cent or
more of its potential capacity, four months, March, February, June and
September, showing but 55, 57 and 59 per cent of use.
The degree of use of the facilities at Lane and Stanford University
Hospital showed somewhat less variation, with a minimum percentage of
64 per cent in April, and a maximum of 77 per cent in March.
The French Hospital facilities showed fluctuations in use from 58 to
72 per cent, in no month attaining 75 per cent of use.
The percentage of use at Mary's Help Hospital showed the widest
variations of any of the institutions, with a maximum of 86 per cent dur-
ing February and a minimum of 54 per cent during November, and with
three of the months — February, June, and April — showing 75 per cent or
more of use.
The Franklin Hospital shows a fairly constant use, three months —
46 Hospital and Heai/th Survey
February, Jul}, and October — showing 75 per cent or more of use, with
the lowest percentage occurring in April and May, when 65 per cent of
the facilities were used.
St. Mary's Hospital shows a general percentage of over 75 per Cent
of use and for four months, over 80 per cent. During March, the hospital
was used to 89 per cent of its capacity, the highest percentage for any one
month for any of the seven institutions. The lowest percentage, 69 per
cent in August, was also the highest minimum for any of the hospitals.
The Children's Hospital shows a fairly constant use of from 55 to 64
per cent. While a children's hospital may show a generally low degree
of use because of the emergencies, such as contagion, arising in their opera-
tion which require that facilities be available when needed, although such
a need may be infrequent, analysis of the very complete statistics assembled
by this institution did not indicate that such was the case in this instance.
The department for communicable diseases during 1922 used 22 per cent
of its available days, the general hospital sections, minus the foregoing,
showing but 64 per cent of use. Further analysis of the days of care fur-
nished to special patient groups reflect a generally low use of the available
capacity. Thus, the maternity department, with 12,410' days available, in
1922 was used to but 59 per cent of its capacity.
It is of interest that on June 21, on which day a census was taken of
the patients in each hospital, 1805 of the beds available, exclusive of those
for tuberculosis at the San Francisco Hospital, were in use. As shown in
the following table, the percentages of use on this day do not differ mark-
edly from those for 1922 as a whole :
* Percentage of Use of Hospitals — June 21, 1923
Number Number Per Cent
Patients Beds of Use
Public Institutions —
San Francisco Hospital 428 643 69
University of California Hospital 149 282 59
Totals 577 925 62
Privately Controlled Institutions —
Children's Hospital 194 275 79
Franklin Hospital 141 214 66
French Hospital 130 200 65
Lane and Stanford University Hospital 252 314 80
Mary's Help Hospital 123 147 84
Mount Zion Hospital 118 150 79
St. Luke's Hospital 119 141 84
St. Mary's Hospital 151 166 89
Totals 1228 1607 70
Grand Totals 1805 2532 71
♦New-born infants and cribs for new-born are not included in estimating percentages.
Services for the Sick 47
The extent to which the hospitals are used suggests that the accommo-
dations represented in this group of institutions afford ample facilities for
the hospitalization of their patients, with possibly the exception of St.
Mary's Hospital. The percentage of use of this institution reflects a con-
tinuously high degree of use, and suggests a demand for additional
(b) SERVICES FURNISHED TO PATIENTS OF DIFFERENT
There are three standard classifications for grouping patients accord-
ing to rate of payment; namely, full pay, those who pay the full cost of
their care ; part pay, or those who pay part of the cost of their care, and
free, those who pay nothing for their care.
The total amount of free service rendered by a hospital is represented
by a number of days for which no part of the cost was paid, plus the free
service furnished to patients paying less than the cost of their care.
In ascertaining this total amount of free service, the free care to part-
pay patients is determined in conjunction with the per capita per diem
cost, and the difference between the amount paid and the cost translated
into terms of days. Thus, a hospital with a per capita cost of $4 a day,
giving 200 days of care at the rate of $3 a day, and 100 days of care at
$2 a day receives $800 for service which actually cost $1200, furnishing
free care to the amount of $400 — the equivalent of 100 days of free care
at the rate of $4 a day.
Due to the small extent to which consideration of per capita costs
enter into the assembling of data regarding part-pay patients in the hospi-
tals, the Survey was unable to determine the actual amount of free ser-
vice thus rendered. In consequence, the number of free days' treatment
includes only the service received by patients paying nothing for their
In addition, the material furnished the Survey indicated that in some
instances part-pay patients, because they pay the rate charged, although it
may be less than cost, are confused with pay patients. These facts should
be borne in mind in interpreting the facts herewith presented regarding the
economic groups served.
During 1922, of the total days of treatment furnished by all ten hos-
pitals, 54 per cent were paid for in full, 12 per cent were partly paid for,
and 34 per cent were free. These facts for the individual hospitals are
shown in the following table and in Chart C, page 49.
Hospital and Heai/th Survey
Full Pay, Part Pay and Free Care, by Hospital— 1922
No. No. No.
Total Full Per Part Per Free Per
Days Pay Cent Pay Cent Days Cent
of Care Days Days
Public Institutions —
San Francisco 158,027 158,027 100
University of California.... 61,049 21,127 34 19,961 33 19,961 133
: Totals 219,076 21,127 10 19,961 9 177,988 81
Privately Controlled Institutions —
Children's 60,128 33,977 65 7,780 13 13,391 22
Franklin 54,813 52,343 95 2,470 5
French 46,663 46,560 99 ...... . . 103 1
Lane and Stanford University 79,138 43,299 55 33,949 43 1,890 2
Mary's Help 34,379 29,946 87 1,975 6 2,458 7
Mount Zion 44,147 25,152 57 8,250 19 10,745 24
St. Luke's 39,457 37,029 94 864 2 1,564 4
St. Mary's 51,766 43,934 85 4,759 9 3,973 6
Totals 410,491 317,220 77 57,577 14 35,694 9
Grand Totals .' 629,567 338,347 54 77,538 12 213,682 34
Of the two public institutions, the San Francisco Hospital furnishes
free care to all patients, with the exception of a few paying patients
admitted to the communicable disease department. The University of Cali-
fornia Hospital does not assemble facts which would indicate the service
which was free to patients, but estimated that one-half of the total days of
care, other than full pay, were furnished without cost and the remaining
half were paid for in part, the cost of maintenance of patients paying noth-
ing, or in part, for their hospital care, being met by State funds.
Of the eight privately controlled institutions, Mount Zion Hospital and
the Children's Hospital gave over 20 per cent of free service, the remain-
ing institutions, Mary's Help, Franklin, French, and Lane and Stanford
University Hospitals furnishing 6 per cent or less of their services free.
The information furnished by the Franklin Hospital, showing 79 per
cent of full pay and 17 per cent of part pay service, was not used as the
9149 part pay days which were given during the year were furnished to
members of the German General Benevolent Society, and for this the hos-
pital received $56,870.95 from the Society. These 9149 days, therefore,
are included with the institution's full pay days.
Likewise, the information furnished by the French Hospital, showing
28 per cent full pay, 23 per cent part pay, and 49 per cent free service,
was not used. The official report of the French Mutual Benevolent Society
indicates that the total hospital service, with tfte exception of 103 free days
of care, was furnished to full-pay private patients or members of the
Society. The 10,696 part pay days and 23,202 of the 23,305 free days,
therefore, were fully paid for and are thus classified by the Survey.
The combined data regarding the economic groups cared for, point to
50 Hospital and Health Survey
the conclusion that, with 77 per cent of the service given to full-pay
patients, the facilities of the privately controlled hospitals are devoted
mainly to this patient group; that, with the exception of the generous free
service furnished at the Children's and Mount Zion Hospitals, only a small
amount of service is given without cost to patients — but 9 per cent; and
that the service to patients paying in part for their care is relatively small —
14 per cent.
These conclusions are borne out by the analysis of the rates being
paid by the patients in nine* of the hospitals on June 21, shown in the
following table :
Rate of Payment of Patients in Hospitals — June 21, 1922
Totals Full Per Part Per Free Per
(100%) Pay Cent Pay Cent Cent
Public Institutions —
San Francisco 428 ... • 428 100
University of California 149 56 38 40 26 53 36
Totals 577 56 10 40 7 481 83
Privately Controlled Institutions —
Children's 194 120 62 36 19 38 19
Franklin 141 101 72 38 27 2 1
Lane and Stanford University 252 230 91 9 4 13 5
Mary's Help 123 97 79 15 12 11 9
Mount Zion 118 70 59 23 20 25 21
St. Luke's 119 115 97 .. .. 4 3
St. Mary's 151 130 86 12 8 9 6
Totals 1098 863 78 133 11 102 9
Grand Totals 1675 919 55 173 10 583 35
One of the important developments in the hospital world is the grow-
ing demand by self-supporting families of moderate means for hospital
This is shown by the demand for beds in small wards accommodating
from two to six persons, a demand which has increased markedly through-
out the country during the past few years.
In hospital operation, analyses of the volume of service rendered to
the various economic groups and the type of facilities demanded, are
increasingly used by hospital boards and administrators as a basis for
determining the character of the provision which must be made to meet
community requirements. For example, a hospital board presented with
facts showing that certain large private rooms are used to but 50' per cent
of their capacity while wards and semi-private wards show 80 per cent of
use would be inclined to convert a portion of the rooms to semi-private
uses. Again, analyses of the percentage of use of the rooms of different
*The information furnished in this particular by the French Hospital was not
used, as it indicated that 37 per cent of the patients were free, nine having been' in
the hospital over a year. As only 103 free days of care were furnished during the last
year, it was suspected that the information sought was not understood.
Services for the Sick
prices might indicate a low use of high-priced rooms and a high use of
moderately priced rooms. Presented with such facts, a board would nat-
urally request data covering a definite period regarding the number of
part-pay patients applying who could not be accommodated, in order to
have an accurate basis for action.
With the exception of Lane and Stanford University, none of the hos-
pitals furnished information which indicates that such analyses are made
and no studies have been made which would show the extent of the demand
for part-pay facilities either individually or collectively. There is, how-
ever, a general sentiment among hospital administrators that increased pro-
visions for part-pay patients are urgently needed.
It must be apparent that the breadth of the hospital service which
these ten institutions make available for the community is reflected in part,
in the nature of the provisions for the different economic groups, as they
determine to a great extent the portion of the sick of the community which
the hospitals serve.
The free hospital beds of the city are the 896 beds at the San Fran-
cisco Hospital and the endowed beds at the privately controlled hospitals,
as follows : ^ <
San Francisco 896
St. Luke's 5
St. Mary's . 6
Lane and Stanford None
University of California None
Mount Zion 50
Mary's Help 2
Comparison of the available free days of care represented in the free
beds at the privately controlled hospitals and the free service given during
1922, indicates that most of the hospitals provide free service exclusive of
that free service to part-pay patients, far in excess of the amount which
could be given if the designated free beds alone were used for this pur-
pose. The chief exception to this fact was Mount Zion Hospital, at which
the part-pay service constituted 19 per cent of the service for the year, a
percentage of part-pay days of care only exceeded by the two university
hospitals. Number of Days' Number of Entirely
Care Available in Free Days of Care
Endowed Beds Furnished During
Children's 10,220 12,390
Franklin 1,460 2,202
French No data 103
Lane and Stanford None 1 ,890
Mary's Help 730 2,458
Mount Zion 18,250 10,745
St. Luke's 2,920 1,564
St. Marv's 2,190 3,073
52 Hospital and Heal/th Survey
It is clear, however, that neither the free service at these hospitals and
the San Francisco Hospital, nor the part-pay facilities generally meet cur-
rent needs, as the information furnished the Survey indicates that the diffi-
culty experienced by physicians and organized social groups in hospitalizing
free patients and those paying moderate rates, is no minor matter. *The
opinions of the members of the San Francisco County Medical Society on
this subject are highly important, and reflect conditions that certainly
deserve special consideration. Individual replies from physicians stated:
'There is a serious need for a hospital for patients who are not charity cases,
but who cannot pay from $6 to $7 a day and up in our private hospitals."
"It has been my experience that the very poor people of this city are better
taken care of than any other class. The need is for some system whereby the
man earning a salary of from $150 to $200 per month can get medical care with-
out going to a free clinic, and thus being pauperized."
"More beds are needed for the man who can pay $10 a week. It costs too
much to be sick. There is nothing new in this statement, and though I have
given it much thought, I can see no way to lower the cost with fairness to all."
"There is undoubtedly a need for more beds at more moderate rates for
wage-earners. I find great difficulty in hospitalizing medical patients, due to the
great expense of hospital beds."
"Hospital beds are needed for free and part-pay patients. There is everlast-
ing red tape to be cut before I can get real assistance for medical patients."
'There are too many boarders in hospitals and too few free beds."
'I firmly believe that the services dealing with the preservation of disease
and the treatment of the indigent are exceedingly well covered. The time must
come, however, when those in moderate circumstances should be placed in a
position where they can buy and pay for medical attention. Private or special
nursing still needs adjustment."
The following are the more important and commonly held opinions
expressed by the social agencies :
"As far as my knowledge goes, we have the best hospital care that I have
known in the entire United States. I do feel this: that the San Francisco Hos-
pital should have a ward or wards where people could pay a fair sum of money
for medical care — $30 or $35 per month, instead of the high and almost pro-
hibitive prices of hospitals for the working class, or the medium class of people,
financially. It is almost impossible for the average wage-earner to pay the prices
charged where they are required to go to wards or to special rooms in the
various hospitals. Some law should be enacted giving the city and county the
right to proceed criminally or civilly, or both, against relatives who are in a
position to pay."
"There is undoubtedly need for more free service at both the University hos-
pitals. It is difficult to get the best work from the pl^sicians who are giving
volunteer service in the clinics if they cannot keep their patients in their own
hospitals when such care is needed. If the patient is placed in the same hos-
pital, the clinician can keep in close touch with his patient through the courtesy
of the staff physicians, even when he must transfer the actual medical care to
"There is a crying need for a department for part-pay patients. The problem
presents itself time and again as patients have to be sent home from hospitals
too soon after severe operations and illnesses because they cannot afford to sta} r
as long as needed."
"It is practically impossible for the unskilled and the semi-skilled, and even
Services for the Sick 53
the skilled, to meet the cost of a long illness if they are unwilling to avail them-
selves of the free clinics or to ask for free care at the San Francisco Hospital,
or if they are not in a somewhat personal relationship to a family physician who
will make special rates for them. For this reason, it is certain that there is a
great need for greater hospital facilities at rates far lower than those now
charged for ward beds.
"At the San' Francisco Hospital there are still empty wards available. If
these wards are not to be needed in the near future for patients who cannot
pay at all, would it be advisable to establish in the San Francisco Hospital the
policy of taking patients who could pay small amounts. If the policy is^ the
right one, the legal difficulty can easily be overcome by getting the Supervisors
at regular intervals to reappropriate to the hospital the money that has been
paid in to the city's general fund. The establishment of this system would prob-
ably net a substantial income to the city, which might be used to supply the
additional nursing service so much needed. Probably many patients are accepted
today as free patients who could afford to pay a reasonable amount, but could
not pay the amount charged in the existing hospitals for ward service. The
establishment of such a policy might be a mistake if the need for free beds was
in the near future apt to grow to the extent of demanding all the space in the
City Hospital. This question of policy must, of course, be determined by the
The physicians' reactions to inquiry as to the adequacy of hospital
facilities indicate dissatisfaction with the delays and obstacles connected
with the admission of patients to the San Francisco Hospital. To quote :
"There is unnecessary delay in admitting patients to the Detention Hospital.
At times this is also true regarding admission to the San Francisco Hospital of
serious cases demanding early attention, and of the Isolation Hospital. "
"I have had difficulty in obtaining bed care at the San Francisco Hospital
for destitute surgical cases."
"It is difficult to get hospital care for medical cases. The City and County
Hospital is seldom available at short notice for medical cases. I have not infre-
quently been informed by patients who are able to pay for care, that they have
succeeded in getting free care, both at the San Francisco Hospital and at clinics.
On the other hand, I have known needy patients to be kept waiting for an
opportunity to enter the San Francisco Hospital."
"It has been my experience that it requires all kinds of references to get
a patient in the San Francisco Hospital. "
"The City and County is very good when they have the room. If they
could transfer some of the 'old chronics' to some other place to make room
for the acute sick it would be a help. Sometimes we have been obliged to wait
three or four days to get a 'worthy' patient into this hospital."
The demand for free hospital beds is greatest during the winter
months, partly due to the climatic conditions and partly due to the fact that
men from the farms, fisheries and lumber camps come to the city during
the winter. The need of hospitalization of these and other groups of non-
resident sick who cannot pay for care and yet are not legitimate charges
upon the city, creates a situation which, in the opinion of members of the
medical profession and social workers, demands attention. To quote some
of the opinions expressed :
"The patient we have the most difficulty taking care of is the man without
funds who comes in from out of town. He is not eligible to a bed at the San
Francisco Hospital, and often needs hospital care or possibly operation. Our
social service workers work hard and do all that can be done, but there are not
54 Hospital and Heai/th Survey
enough Funds available to provide for many of these fellows who are in need of
"More Free bods are needed, especially for non-residents of the city and of
the State. The transient population offers a large problem in California — the
financial aspect is not the least important. May I suggest that the charities of
the country establish a service similar to the clearing-house of the banks?
Through such an institution the transient sick poor could be treated, in the city
of their new residence and be supported by the charities of their home cities."
'The chief difficulty I have encountered has been the cases of indigent sick
who have not been in San Francisco for the required length of time to qualify
for the San Francisco Hospital. If a man drops in the street the Central Emer-
gency Service must look after him, but as long as he can drag himself around
there is no place for him."
'More free beds are needed for patients not eligible to the San Francisco
Hospital. I have difficulty in regard to the patient from outside the county who
has no funds and who needs surgical treatment not available in his own county."
It must be obvious that, collectively, these opinions indicate that there
are unsolved problems of importance to the city's sick and to the progress
of medical care and medical education in San Francisco. The community
is fortunate in having within its midst such a wealth of interest and indi-
vidual appreciation of the desirable elements of community health service,
for they constitute a nucleus for fair and unhurried study of the subjects
(c) MEDICAL SERVICES MAINTAINED
All of the ten hospitals receive patients with general medical and sur-
gical conditions, and maternity patients. But two of the institutions, the
San Francisco and Children's Hospitals, receive patients suffering from
acute communicable diseases. One, the Lane and Stanford University
Hospital, receives patients with mental and neurological conditions. None
of the hosptials, with the exception of the San Francisco Hospital, receive
patients with venereal diseases or with active pulmonary tuberculosis.
The chief fact indicated by the foregoing limitations of service are
the restrictive policies regarding neurological conditions, tuberculosis, and
venereal diseases in the private hospitals, discussed in Section II.
As mentioned earlier in this section, the ten hospitals, as a group, pro-
vide all the accommodations in the city for acute communicable diseases
and tuberculosis, and 94 per cent of the beds definitely set aside for the
care of particular conditions.
Exclusive of the 250 beds for tuberculosis at the San Francisco Hos-
pital and the 146 beds for acute communicable diseases at the San Fran-
cisco and Children's Hospitals, the beds assigned to the various medical
services in the ten hospitals are as follows :
Services for the Sick 55
Beds Assigned to Various Medical Services
Medicine — Beds
General Medicine ' 320
Pediatrics (including 114 for new-born) 249
Neurology . 1°
General Surgery 304
Ear, Nose and Throat 2
Used Interchangeably 113o
Grouped according to the four main services, as below, the number of
beds for medicine exceeds that for surgery, although this is not the case
if the 75 beds for venereal diseases at the San Francisco Hospital are
excluded from the first-named group:
Medicine . 433
Used Interchangeably 1135
It is generally felt that there should be as many beds available for
medicine and the medical specialties as for surgery and the surgical spe-
cialties, but the facts collected do not indicate that this is the case in this
group of hospitals. The high proportion of the beds provided for surgery
is further emphasized by the fact that a large percentage of the beds not
definitely assigned and used interchangeably in the ten hospitals, and a
still larger percentage of the beds in the nine hospitals of the city not
included in this Survey are, as a matter of experience, used for surgical
Hospital and Health Survey
The facts collected on June 21 indicate the ratio of the medical, sur-
gical and obstetrical patients in the individual hospitals on one day:
Percentage of Medical, Surgical and Obstetrical Patients in Hospitals
June 21, 1923
Per cent Per cent
Public Institutions —
San Francisco (including Contagion) 52 42
University of California 36 50
Privately Controlled Institutions —
Lane and Stanford University 37
Mary's Help 32
St. Mary's 31
A further analysis of the census day data, showing the number of
patients under the supervision of the various medical services at the dif-
ferent hospitals, is given in the following table:
— Institutions — Privately Controlled Institutions
i— ■ • *
i— > •
General Medical. .. 133
General Surgical. . . 146
Ear, Nose and
Genito-Urinary ... 3
Gynecological .... 17
Communicable .... 64
Not stated 3
Totals 428 149 177 194 141 130 252 123 118 119 151 1228 1805
Services for the Sick 57
Although the foregoing facts present the experience of but one day
and, therefore, cannot be taken as conclusive, they indicate to some degree
the type of medical conditions hospitalized in the several institutions. At
some of the hospitals the patients under the supervision of the subsidiary
medical and surgical services were not so classified as to permit such
an analysis. At four of the hospitals, the Franklin, St. Mary's, Mary's
Help, and St. Luke's Hospitals, the patients were classified only under the
three main patient groups — medical, surgical, and obstetrical. At the Uni-
versity of California Hospital, in addition to the foregoing classifications,
pediatric and gynecological patients were separately indicated. At the
French Hospital, eye, ear, nose and throat, genito-urinary and gynecologi-
cal classifications were used. At the Children's Hospital, in addition to the
medical, surgical, and obstetrical, pediatric and communicable diseases
classifications, orthopedic and neurological patients were separately grouped.
At San Francisco, Lane and Stanford University, and Mount Zion Hospi-
tals the classifications, according to major subdivisions of medical service,
were more precise and numerous than in the other hospitals.
The experience of San Francisco with the hospital isolation of the
common communicable diseases of childhood is interesting because of
its general similarity to that of other cities of the country of 500,000
population and over:
( San Francisco, June, 1922-May, 1923 . Percent
Patients ^Vff i tl! z ^ d
Cases Re- Hospitalized United States
ported to San Francisco Per cent nf c nn mn r> nn
Health Deaths and Children's Hospital- IS ftP ?„ P ." r
Department Reported Hospitals ized 1920
Diphtheria 1265 108 429 33.9 24.3 '
Scarlet Fever .... 630 8 171 27.1 25.3
Measles 781 8 61 7.8 3.1
Whooping Cough. 568 28 44 7.7 2.1
Apparently San Francisco hospitalized a higher percentage of patients
with these diseases than is the case generally in other large cities, but the
difference in the practice of communities in reporting diseases must be
taken into account before accepting this table as showing an entirely cor-
rect comparison between the per cent hospitalized in San Francisco and
that in other cities.
The number of days' care furnished to the various patient groups —
the true basis for determining the relative amount of hospital service
devoted to the various medical services — is not known, due to the fact that
but three of the hospitals, the Children's, Franklin, and University of Cali-
fornia Hospitals, assemble these important data. The percentage of ser-
vices furnished at these three hospitals during 1922, grouped according to
medical service were :
Medical Pediatric Surgical Obstetrical
Per cent Per cent Per cent Per cent
Children's 6 67 14 12
Franklin 21 . . 72 8
University of California 25 14 42 14
58 Hospital and Health Survey
It is unusual to find a group of hospitals accumulating and assem-
bling so little information for their own use or for the public, regarding
the character and amount of service which is furnished the various patient
groups. The methods of assembling and analyzing facts used in the lead-
ing hospitals of the country have not yet been adopted. Thus, many- hos-
pital executives review monthly the percentage of use of the beds assigned
to the different services, for the information of their boards and attend-
ing staffs. For example, a hospital with the beds assigned to neurology
showing a high degree of use and with those assigned to dermatology,
gastroenterology, etc., showing low percentages of use, has problems
related to service for the sick and to intern and nursing education which
can be intelligently acted upon. Is the low use of certain beds due to
too liberal assignments to these specialties or to the conduct of these ser-
vices, in either the hospital or the dispensary? What are the causes for
increased demand for beds in one service and decreased demand for
another service? For what percentages of these special groups is bed
care needed to meet the sickness demand of the community? What must
the range of cases include to furnish interns and student nurses with a
comprehensive experience in the particular disease groups?
With the exception of the data furnished by the Children's Hospital,
no facts were available which permit of even brief analysis of the various
medical groups served. As the data collected by this one hospital are not
analyzed with reference to the extent to which its facilities are used or to
the sickness needs of the community, their chief value is lost.
The combined medical opinion on the subject of hospital accommoda-
tion suggests a general need for increased beds for general medical condi-
tions, with special emphasis upon the needs of mental and neurological
patients, the inadequacy of the accommodations for children and for
patients suffering from eye conditions and venereal diseases. To quote:
''There is no way of keeping under observation or treatment acute and bor-
der-line mental patients. No systematic psychiatric work is being done that I
"Service for mental cases, and especially acute delirious cases, is extremely
poor. No hospital will keep them. They receive wholly inadquate care at the
Detention Hospital and are sent to Napa. Private hospital facilities for psychi-
atric patients should be available at the San Francisco Hospital."
"I have great difficulty in obtaining free beds for nervous and mental
patients. There are beds available at $3 a day to take care of the patients who
can pay this fee, but funds for free beds are very limited. More beds are needed
at the San Francisco Hospital for free mental patients."
"I would call your attention to the utter lack of any provision for patients
with the milder forms of mental diseases. There is no space where a clinic
patient can be placed for observation and care. He must be left an out-patient
or be committed to the State Hospital. There is also a great need of a similar
place for patients of moderate means. The minimum rate of privately owned
institutions is $35 a week/'
'There are no adequate means of caring for private or clinic patients with
mental disturbances. A psychiatric hospital — a ward at San Francisco Hospital
or at the University of California Hospital would be an immeasurable boon to
Services for the Sick
the community — there being absolutely no means in the city adequate to the
needs of mental cases."
"I can find no place in San Francisco for free or part-pay care of open
tuberculosis in young children."
"In the question of treating an individual with tuberculosis as matters now
stand only the advanced cases can get hospital care, and naturally prognosis is
poor. The early case is the one on which attention should be focused and bed
care provided in a hospital if good results are to be obtained instead of treating
them as now treated — ambulatory cases at out-patient departments."
"There is a great need of an extra-urban tuberculosis hospital."
"The chief necessities in tuberculosis work are — a sanitarium for ambulatory
and semi-ambulatory groups, and increased nursing and trained professional
"I have difficulty in hospitalizing pulmonary tuberculosis cases that are unable
to pay for sanatorium treatment."
"There is a crying need for taking care of malignancy along modern lines.
I have great difficulty in handling patients with malignant diseases who need,
but cannot afford to pay for the cost of Roentgen therapy."
"San Francisco has poor provisions for contagious cases. I find there is
little done systematically for heart cases."
"The facilities for venereal patients are inadequate. The San Francisco Hos-
pital will take such patients, but the other hospitals will only take such cases in
private rooms, which usually means that, as a rule, a patient is not hospitalized
as he cannot pay the price. As a result, they are a menace in the home or in
public places, such as hotels, rooming-houses, etc."
The foregoing opinions and similar data presented earlier in this
report, point to the difficulties experienced in obtaining hospital care for
patients with limited means, suffering from particular illnesses.
An analysis was made of the information* collected on the census day,
relative to the number of medical, surgical, and obstetrical patients which
were full pay, part pay or free, with the following result :
Full Pay Part Pay Free Total
Per Per Per Per
cent cent cent cent
Medical 44 9 47 100
Surgical 61 11 28 100
Obstetrical 69 9 22 100
(Not stated) 82 .. 18 100
These percentages indicate that on the day in question approximately
one-half of the medical patients were free, something less than one-half
paid fully for their care, 9 per cent being part pay. Of the surgical
patients only 60 per cent were full pay, less than 30 per cent free, and 11
per cent part pay. Of the obstetrical patients practically 70 per cent were
full pay, a little over 20 per cent free, and 9 per cent part pay. The strik-
ing facts are the small extent to which the part-pay patients in any of the
three groups were hospitalized, the high percentage of full pay surgical
and obstetrical patients, and the large percentage of free medical patients.
As similar analyses for the hospitals as a group could not be made,
♦Exclusive of the patients at the French Hospital.
60 Hospital and Health Survey
due to the lack of the facts for such a study, it is not known whether this
experience on the census day represents the usual conditions. To be of
value and to serve as a basis for so important a matter as rate-setting and
redistribution of beds to medical services, comparable data, covering a
number of months should be assembled by each hospital.
Inadequacies of Hospital and Medical Services
There are certain aspects of the services for the sick which received
attention from the medical profession in replies to inquiry from the
Survey, and certain inadequacies of hospital and medical care revealed
through study, which should be considered.
Specific conditions mentioned by physicians relate to various phases
of the care of the sick of the community and, although not included in
the matters receiving the attention of "the Survey, are highly important.
The following opinions call attention to conditions which relate to or
hamper hospital medical service:
It is difficult to hospitalize pneumonia patients.
Night clinics are needed for women who work.
Reports to physicians from hospitals are unknown.
Provision for after care of drug addicts is inadequate.
Provisions available for the handicapped are inadequate.
Wet nurses are needed at all hospitals.
Dental work is limited to emergency treatments.
Facilities for the rehabilitation of cripples are needed.
There are too many boarders in hospitals.
Auxiliary diagnostic facilities are costly.
There is too little control of laboratories.
Laboratory fees are too high.
Salvarsan at cost can only be obtained with difficulty.
There are insufficient X-ray films at the City Hospital.
The after care of hospital patients is a responsibility of the medical
staff and the determination of a program for after care is a medical
matter which cannot properly be delegated to others.
The need for after care as reflected in the character and extent of
instruction to patients prior to discharge and the provisions made for
return -to complete health, is one that is only partially met in the ten hospi-
tals. Case after case visited during the course of the convalescent study
of the Survey indicated this defect of medical care.
Although the majority of the hospitals maintain contact with certain
types of cases following discharge — some of them providing nurse follow-
up of special patient groups — after care is provided for relatively few
In a large percentage of the 160 patients visited in their homes, con-
tact with the medical staffs responsible for their care had ceased on dis-
Services for the Sick
charge, and no provision had been made for other subsequent medical or
nursing supervision. This fact is illustrated by the following cases :
Case No. 1 — A patient who had been operated upon in one of the hospitals,
where she remained for four weeks, had a fecal fistula on discharge. Following
her return home she had a severe hemorrhage, but as the hospital had no bed
available, she went to another, where she remained five days, and was discharged
unimproved with a diagnosis of carcinoma of the cervix and recto-vaginal fistula.
When visited she was sick in bed, had no means of obtaining the nursing care
demanded by her condition, and was in need of immediate hospital care. The
hospital in which the patient had been for so long under treatment was using
less than 60 per cent of its available beds at this time.
Case No. 2 — A case in which continued medical supervision was needed was
that of a patient who, when she came to San Francisco, was under treatment at
one of the dispensaries for syphilis, but as the salvarsan made her sick, she
only took a few treatments. About a year later, when pregnant, she went to
another hospital for prenatal care, having regular urine examinations but no
blood examination. Her baby lived four months, was always sick and was taken
care of as a free patient in a third hospital. The patient, when visited, was
recovering from an operation for appendicitis and was referred back to the first
dispensary by the visitor for the Survey for examination and treatment of her
Case No. 3 — This patient, a child of two years, who had been removed from the
hospital against the advice of the staff physician, but whose condition was suffi-
ciently serious to require special attention even under the foregoing circum-
stances, had fallen from a second story window to the sidewalk, probably strik-
ing his head, as blood ran from his nose and ears and as he was unconscious
for seven days. On leaving the hospital, one ear was discharging pus, and the
mother was told by the doctor that the child should continue under medical
supervision and to take him to a public dispensary, distant from her home.
Although she stated she was keeping a boarding-house and could not go so far,
she was not told that she lived only a few blocks from another dispensary.
When visited, the child's ear was still discharging pus. As the doctor at
the hospital told the mother to irrigate the ear, but had not told her what to
use, she had been irrigating the ear with lysol solution as strong as the child
Not only was this patient in need of home nursing care and dispensary care,
but, due to the poor instructions the mother received, he was having treatments
which were seriously unsuitable, if not dangerous.
Case No. 4 — This case, indicating a need for persistent follow-up, was a child
of five with club feet, who had been a free patient in the hospital for a month.
When much younger he had been under treatment and wore a cast, but because
of the expense his parents had neglected to keep up with the treatments, so the
work had to be done all over again. While in the hospital, the child had had an
operation and a cast applied on one leg, and was shortly to return to have
similar treatment for the other leg. The home was exceedingly dirty, the mother
ignorant, and the instructions given her had not been understood. It should
have been obvious, in dealing with the case the second time, that favorable end-
results depended on special supervision and instructions, but there was no indi-
cation that the seriousness of the situation had been made clear to the parents.
We have only to contrast the foregoing and other cases cited later
in this section, with the following instance of excellent follow-up and
after care, to point out the results which are possible when there is a
program for further care, and when sufficient workers for follow-up are
Case No. 5 — The patient, a three-year-old child with one leg shorter than
62 Hospital and Health Survey
the other due to congenital syphilis, had been in the hospital for only a short
period for observation and treatment, but had been for many months under the
supervision of the out-patient department. The parents had been fully instructed
at the clinic regarding the child's condition, treatments, etc., and follow-up visits
had been made to the home by the hospital's social service department, so ,that
every precaution was being taken to secure favorable results. The parents knew
the character of the treatments, that they would have to be continued for many
months, and that everything was being done that the hospital could do.
This case is illustrative of the many cases visited in which the follow-
up was effective and in which careful instruction had been given by the
physician or surgeon responsible for the case.
The picture presented by those patients who sought the instruction
and medical direction which should have been provided as part of their
medical care without effort on their part, is a serious one:
Case No. 6 — A little boy of eight, who had been in the hospital over two
months with a fractured femur, was discharged to his mother with insufficient
instruction. As his right leg was in a cast from the hip to the ankle, she asked
the nurse in charge of the ward how to care for him. The nurse declined to give
any advice and referred her to the doctor. The mother had to hunt him up
herself and found him in a room doing a dressing. The only instructions he
gave her were to take the child to a public dispensary. The boy was kept in
bed for a week after returning home and was then allowed to use his leg. After
ten days the mother telephoned the same doctor at the hospital and asked him
when she should take the boy to the clinic and what she should tell them there.
When it was understood that the boy had been permitted to walk, the mother
was told to keep him off his feet for a week and then to bring him back to the
hospital, because the doctor was afraid the bone might not have united com-
pletely, as it had been used too soon.
Case No. 7 — Another case, a little girl of six in the hospital two days fol-
lowing a tonsillectomy, was brought home in an ambulance. The mother had
received no instructions regarding the after care of the child, so, as the patient
was suffering, she took her back to the hospital, four days after discharge, to
find out what should be done.
Case No. 8 — A woman who had been in the hospital for two weeks with
neuralgia, arteriosclerosis and hypertension was given no instructions on dis-
charge, nor referred to any dispensary for follow-up. As the patient felt ill and
weak after leaving the hospital, she went back to see the doctor who had cared
for her, but she was unable to talk with him because he was busy. She then
went to the ward and asked the mirse in charge if she could make arrangements
to see the doctor. The nurse was new and did not know the patient, so she
was apparently not much interested and said the doctor might come in any
minute or he might not come in at all.
The needs of a large number of patients would have been met by
reference to a dispensary where they could have obtained the needed medi-
cal supervision. To cite a few of those showing the more serious needs:
Case No. 9 — A man of 50, in the hospital almost two months because of a
fractured leg, was given no instruction on discharge from the hospital, or the
name of any dispensary where he might go for medical supervision or needed
physiotherapy. His leg was still very stiff from the cast and the patient was
worried about his slow improvement. He was in need of advice as to where
he could obtain the needed medical care, special treatment, and medical opinion
regarding the condition of his leg.
Case No. 10 — A little girl of five, in the hospital for sixteen days with ton-
sillitis, was discharged to her mother without instructions as to her further care.
Services for the Sick
The mother did not speak English and may have misunderstood directions, but
she knew of no place to go for free instruction for the feeding and care of either
this child or of her ten months' old baby. A physician had made all arrange-
ments for her at the hospital where she paid $2.50 a day, but she could not
afford the expense of a private physician for further medical care.
Case No. 11 — A homeless man of 36, in the hospital for almost two months
with acute arthritis, when discharged went to a rooming-house. He was without
money and was being suported by friends who felt sorry for him, giving him
25 cents a day for his meals. Some days he had one meal and some days
three meals. All his teeth were removed at the hospital, but as he had no
money to get new teeth, and as he was not referred to any dispensary for dental
or other care, his condition was unknown to the agencies which might have
assisted him. He felt his condition was almost as bad as when he first went to
the hospital. The patient was referred by the worker for the Survey to the
social service department of the dispensary to which he should have been
referred, and he was immediately provided with the needed medical and dental
There is no one patient group probably for which the need for instruc-
tion has been so emphasized as the maternity patient. While the follow-up
for such cases is excellently provided for by some of the hospitals, in
others there is no plan for further care, as illustrated by the three follow-
ing cases, all patients at the same hospital :
Case No. 12 — The patient, a private patient, was a young Portuguese mother
of 19 who had had her first baby. She was the type who would attend and
would be much benefited by a well-baby conference such as is conducted at
the Emporium. The mother and baby were in good condition, but the mother
was entirely ignorant about feeding and baby care.
Case No. 13 — This mother was in need of medical care and had just called
her private physician who had delivered her at the hospital. The baby was well,
although it was the mother's practice to nurse it whenever it cried. Its feet and
legs were tightly wrapped, preventing any movement, and the surroundings were
unhygienic, entirely lacking needed ventilation. This mother also is the type of
patient who would attend a well-baby conference, but had not been recom-
mended to the one in her neighborhood.
Case No. 14 — This mother feeds her twins at irregular intervals and needs
instruction in the general care of babies, also in the preparation of supplementary
feeding. She was not referred to any well-baby conference and only consults
her private physician in case of sickness.
The time to arrange for a patient's after-care is prior to discharge.
It is natural to suppose that medical care includes inquiry regarding home
conditions, instructions as to physical condition, and directions as to the
course to be followed after leaving the hospital and, in those cases in which
social service investigation reveals social or economic problems, reference
to the social service department so that adjustments will be made which
will insure the patient the particular institutional care needed. The follow-
ing indicate that such medical supervision is not always provided :
Case No. 15 — A little boy of three was discharged after six days in the hos-
pital with a diagnosis not definitely determined but judged to be sub-acute tuber-
culous peritonitis. The mother was told to take him to the hospital's dispensary
and was given detailed instructions about his care. The hospital's nurse had
called and advised preventorium care, because, although the mother is intelligent
and the child is receiving good care at home, as there are two other children
under four, she had insufficient time to carry out the instructions. It was quite
apparent that the mother's entire time was being taken up in care of the sick
64 Hospital and Health Survey
child, to the detriment of the other children and to her own health. The ques-
tion of preventorium treatment had not been taken up with the mother by either
the doctor or intern, and although evidently recommended by the physician in
charge of the case, its importance had not been brought home to the parents.
Case No. 16 — Convalescent institutional care was indicated for a man of 38
who had been for a month in the hospital with chronic nephritis. He had had
many previous attacks and had been ill and unable to work for over three
months. He felt he had been much improved by his hospital stay, the pufriness
had gone from his hands and feet, but he was still weak, thin and anemic. Pre-
viously he had done janitor work, and a physician at the hospital had told him
he might be able to run an elevator. His physical condition indicated that he
was not able to work, when visited shortly after discharge. His wife is lame
and able to earn a little money by sewing at home. One of the relief agencies
has given aid on different occasions, and at the time it was giving a quart of
milk a week. It was the opinion of the visitor for the Survey that the wife was
not able to provide the proper care and diet required by the patient's physical
condition, and what he needed was institutional convalescent care, followed by
occupational placement. He was referred to those conducting a study of the
handicapped, in progress at. the time, and employment suited to his condition was
to be arranged for.
Case No. 17 — A young woman of 21 with no family or home, who was in the
hospital for over three weeks with heart disease, went to a rooming-house on dis-
charge. She was working in a laundry, her legs and feet were swollen, and she
felt she would soon have to return to the hospital again. This patient should
have been in a convalescent institution where she would have the special medical
supervision and be referred to an agency for assistance in obtaining work suited
to her heart condition. •
Throughout the hospitals of San Francisco there are but two occupa-
tional aids, one each at the University of California, and the Lane and
Stanford Hospitals. The well-known benefits to be obtained during;
the period of bed care of hospital patients through the stimulation and
direction of occupations, provided by trained persons acting under
medical advice, for therapeutic purposes can hardly be said to be appre-
ciated by the medical or administrative staffs of the hospitals of the city.
Occupation of patients of almost all types appears to aid in recovery, to
make easier ward management, to abbreviate the length of stay of patients,
and assist in many ways functional repair, particularly in surgical and
orthopedic cases and among psychiatric patients.
It is understood that the salary of the occupational aid at Lane and
Stanford Hospital is supposed to be a suitable burden for the Community
Chest, and at University of California Hospital an appropriate item for
the Women's Auxiliary to support.
The position of occupational therapeutist or aid in a general hospital
should be as definite and integral a part of the hospital staff, as is the
anesthetist, the dietitian or the dentist.
Instead of considering this a service only for the amusement of
patients, and a matter of unconcern to the attending medical staff, this
resource in the treatment of disease should be used intentionally by
physicians and surgeons, by calling upon the occupational aid to plan
for treatment as they do the serologist, the pharmacist and the dietitian.
Services for the Sick 65
While the simple occupations of bead work, jewelry, weaving and
basketry serve to introduce the function of occupational therapy into
the hospital household, they do not represent the full range and scope of
manual trades, etc., which could be used with great advantage, especially
among the 9 per cent of patients in San Francisco's Hospitals who have
been bed patients for three months or more, many of them for several
A study of the uses of occupational therapy as developed in many
general hospitals throughout the United States would be an interesting and
probably a profitable undertaking for the proposed Hospital Council.
The experience of the Massachusetts General and the Children's Hospitals
in Boston, of Bellevue Hospital in New York, of Barnes Hospital in St.
Louis, and of the Presbyterian Hospital in Chicago would be illuminating
and stimulating to any of the hospital executives of San Francisco who
have opportunity for observation of hospital work elsewhere.
Attention should be called to the meager development among the ten
hospitals, of clinical staff meetings. A few of the medical staffs meet with
regularity and review certain phases of professional care, but such review
cannot be considered to be complete if the conference programs are lim-
ited to interesting or unusual cases, do not include the review of private
patient's records, special patient groups and particular services, or do not
include the presentation of cases which come to autopsy.
The organization of staff conferences, which are intended to serve
the purpose of a professional forum before which every record of service
may be brought for searching analysis as to method and result of treat-
ment, is perhaps the most important function of a medical board.
Such conferences are growing steadily in value and suffer more from
the lack of adequate preparation of the records upon which discussion
must be based, than from indifference or lack of recognition of their
worth. The points which should receive more attention from the several
staffs are: (a) The use and results of consultant services where special
problems of diagnosis and treatment are present; (b) The analysis of
cause of death, particularly in obstetrical services and after operations of
choice; (c) Infections following "clean" operations, post-operative pneu-
monia, etc.; (d) Unsatisfactory results of treatment requiring readmis-
sion, and (e) Complications which might have been avoided.
It does not appear that the weekly colloquia conducted separately by
the different services of the two university staffs at the San Francisco
Hospital meet all the requirements of staff review of professional per-
One way of measuring the interest in and practice of scientific clinical
medicine is by the percentage of deaths that come to autopsy. Where there
is indifference as to the accuracy of diagnosis, or what Dr. Richard Cabot
66 Hospital and Health Survey
so tersely described as the "sins of omission and commission/' we find that
little attention is paid to that final verification of medical skill or the
humbling process of facing one's own error which can take place only
at the post-mortem examination.
During 1922 according to the answers received from the hospitals by
the Survey no autopsies were performed at St. Luke's, Mary's Help, or
Mount Zion Hospitals among the 336 deaths which occurred in these
institutions in the year. Apparently there were no autopsies performed
at the French Hospital, the number of deaths, however, being omitted
from the report from this hospital.
At the Franklin and St. Mary's Hospitals autopsies were performed
in 1.9 per cent or four of the 208 deaths, and 8.1 per cent or eleven of
the 135 deaths, respectively. At the Children's Hospital autopsies were
performed in 39.5 per cent (sixty out of 152 deaths). At the three hospi-
tals used for teaching purposes, with the attending stafTs nominated by
the medical schools, autopsies were performed as follows in 1922:
Deaths Autopsies Per cent
San Francisco Hospital 599 137 22.8
Lane and Stanford.... 252 44 17.4
University of California . * . 42.0
Making all suitable concessions for racial and religious prejudices and
superstitions, it cannot be said that this is a good showing. There is
little resourcefulness or determination used in securing consent for post-
mortem examinations. This is distinctly a function of the hospital ad-
ministration, although interest and persistence on the part of the at-
tending and resident staff is a powerful aid to success. When the Mon-
treal General Hospital, Peter Bent Brigham Hospital in Boston and
Mount Sinai Hospital in New York can obtain consents for autopsies in
over 85 per cent of the deaths there ought to be more than one hospital
in San Francisco to claim as much as 42 per cent of autopsies.
(d) AREAS SERVED
Although the majority of the hospitals have some general idea of
the sections from which they draw their patients, there is no definite
knowledge on the subject as no studies have been made which would fur-
nish these facts. In order to obtain information from which deductions
could be drawn regarding the areas served by the several institutions, a
study was made of the addresses of 6542 patients — representing the cases
admitted to the ten hospitals during two months, November, 1922, and
The results of this study indicated that 84 per cent of the patients
admitted during the period were residents of the city and 16 per cent
were non-residents, the percentages varying for the individual hospitals, as
Services for the Sick 67
Percentage of Residents Among Hospital Admissions, November, 1922,
and January, 1923 .
Public Institutions —
San Francisco Hospital 99
University of California Hospital. . . 64
(21 per cent no address or wrong address.)
Privately Controlled Institutions —
Children's Hospital 80
Franklin Hospital 80
French Hospital 91
Lane and Stanford University Hospital 65
Mary's Help Hospital 90
Mount Zion Hospital 89
St. Luke's Hospital 84
St. Mary's Hospital 78
Average 84 per cent.
68 Hospital and Health Survey
In order to ascertain the specific areas served by each hospital, in-
dividual maps were prepared showing the geographical distribution of the
patients admitted to each institution during the period specified. Based
upon the results of this further study, the general areas served by the
several hospitals are herewith briefly outlined:
Of the two public institutions, the San Francisco Hospital serves
primarily the Potrero and Mission districts, the Western Addition, and
those sections south of Market Street which border on the general neigh-
borhood of the hospital; the University of California Hospital serving its
own immediate locality and the section bounded by Stanyan, Seventeenth,
Turk and Fillmore Streets, largely. The admissions tx> the first-named
institution constituting the largest number of free patients cared for dur-
ing the period studied, a further analysis was made of the sections served
by this hospital, as shown in Map 2, page 69. As the city is not divided
into the usual municipal health districts, the districts used are those com-
monly used in designating the various sections of the city.
Of the privately controlled hospitals, the Children's Hospital appar-
ently serves all sections of the city, with the exception of the Potrero
district. There does not appear to be any particular section which is
served more than any other, the number of patients coming from the
different parts of the city varying with the density of population.
The Franklin Hospital admitted patients from all sections of the city,
there appearing to be no particular district served more than any other.
The patients admitted to the French Hospital came chiefly from the
district bounded by Fillmore, Market and Larkin Streets, the neighbor-
hood of Telegraph Hill and from its own neighborhood.
At Lane and Stanford University Hospital, though patients were
admitted in large numbers from all sections of the city, the section
served appears to be primarily that in which the institution is located.
Mary's Help Hospital serves chiefly its own immediate district — a fact
which was also true of its dispensary service, based upon the addresses
of new dispensary patients admitted during the same period.
Mount Zion Hospital, while admitting patients from all sections of
the city, serves the general area north of Market Street out as far
as Golden Gate Park, the great majority of the patients living in the
section bounded by Market, Fillmore, Geary and Larkin Streets, and a,
large number coming from the hospital's own neighborhood. At this
hospital, also, the new dispensary patients during the two months studied,
came chiefly from the same general districts as the hospital cases.
At Saint Mary's Hospital, the greatest number of patients came from
the hospital's own section of the city, although many of them were ad-
mitted from the general metropolitan area.
St. Luke's Hospital serves all parts of the city excepting the extreme
western and eastern portions, the striking fact being the uniformity
with which patients were received from all sections.
Auwnoo OJUVA/ MVP
70 Hospital and Health Survey
These combined data reflect general and special areas served by the
individual hospitals. It is to be expected that the two University hospitals
admit patients from all sections and that most of the other institutions
serve their own localities to varying degrees. The facts indicate that many
of the hospitals draw from practically all sections of the city, and that
Marys Help, Mount Zion and St. Luke's Hospitals receive patients in
reater proportion from their own neighborhoods.
Of the two publicly maintained hospitals the San Francisco Hospital,
supported by city taxes, has made no request for community support
from the Chest. Matters of finance at this institution therefore were not
considered by the Survey.
The University of California Hospital, supported by fees from
patients, State taxes and income from endowments, furnished the Survey
with a brief financial statement indicating the sources of income, and a
total, but no items of expenditures.
Of the privately controlled institutions, the Children's, Mount Zion,
St. Luke's, Mary's Help, St. Mary's and Lane and Stanford University
Hospitals are supported by donations from the public, income from opera-
tion and interest on investments; St. Mary's and Mary's Help Hospitals
receiving additional contributions represented by the services donated by
The two remaining private institutions, the Franklin and French
Hospitals, are the activities of mutual benefit insurance associations, and
in addition to the income from operation, donations, etc., receive support
from their respective actuarial memberships.
During the last fiscal years of the ten hospitals the total hospital
income, including $713,000 expended for the maintenance of the San
Francisco Hospital, amounted to $3,794,598.01. The several sources from
which this sum was obtained were not clearly indicated in the financial
information furnished, due largely to dissimilar accounting methods. The
following table presents the facts in as much detail as the figures furnished
Services for the Sick
Sources of Hospital Income, 1922
Public Institutions —
San Francisco ..$713,000.00
University of California. 176,505.23
Totals $889,505.23 $339,301.09 $11,414.38 $1,240,220.70
Privately Controlled Institutions —
French (Society and Hos-
pital income not sepa-
Lane and Stanford Uni-
Totals $2,147,762.05 $173,219.80 $2,554,377.31
$889,505.23 $2,487,063.14 $184,634.18 $3,794,598,01
*(25%) *'(70%) *(5%) *(10O%)
The foregoing is assumed to be indicative of the general situation
regarding the sources of hospital income. It is probable that the con-
siderable donations and endowment fund income of the Children's Hospi-
tal, which do not appear on the foregoing table, would not materially
increase the percentage of total income thus derived, as they would be
largely offset by the income from operation of the French Hospital — an
item which also was not furnished the Survey.
Special mention should be made of the matter of the free services
donated by the Sisterhoods conducting St. Mary's and Mary's Help
Hospitals. As Sisters' services represent a financial saving to a hospital,
the actual money equivalent should be estimated and listed as a donation
from the Sister personnel. The amounts, therefore, listed as income from
donations at St. Mary's and Mary's Help Hospitals represent the money
equivalent of donated Sisters' services, and were computed by the
Survey on the basis of current salaries for the positions held by Sisters
in these two hospitals. The importance of the contribution of the Sister-
hoods maintaining the two hospitals does not receive due recognition
unless this is done. In securing cost items for purposes of comparing
costs with those of other institutions, such estimates should be included as
salary items, and, in recognition of the services donated free by the
Sister personnel, they should be included in public statements of funds,
contributions, materials, etc., donated to these hospitals.
♦French Hospital income eliminated in finding- percentages.
72 Hospital and Health Survey
The finances of the French and Franklin Hospitals present special
problems as these two institutions are essentially the undertakings of
mutual benefit organizations. As the French Hospital did not furnish
the Survey with the financial information supplied by other institutions, the
facts reviewed were those contained in the organization's last- published
report. These indicate that the hospital and Benevolent Society are con-
ducted as a unit and that the undertaking for the fiscal year, ended in
March, 1923, showed a profit of some $14,000. The facts furnished b^
Franklin Hospital indicate that the institution is a subsidiary of the
German General Benevolent Society, to which rental is paid for the use
of the hospital plant. For 1922 the hospital showed a net profit from
operation of $545, which sum was applied to the reduction of the $34,000
deficit arising through the mutual insurance activities of the Society.
The total expenditures of the ten institutions during 1922, amounting
to $3,752,412.70, is shown for the individual hospitals as follows:
Hospital Expenditures, 1922
Public Institutions —
San Francisco Hospital $ 713,000.00
University of California Hospital 527,220.70
Privately Controlled Institutions —
Children's Hospital , 280,433.18
Franklin Hospital . . 369,317.47
French Hospital (Society expenses included) 219,303.19
Lane and Stanford University Hospital 585,419.38
Mary's Help Hospital 152,109.02
Mount Zion Hospital 335,607.40
St. Luke's Hospital 317,490.74
St. Mary's Hospital 252,511.62
Grand Total . . .......; $3,752,412.70
Due to the incompleteness and the differences of classification of
expense items, it was not possible to analyze the relative amounts expended
for the various items of hospital maintenance. These are important as
indications both of service given and administrative policy, in that they
show the amounts expended for the various phases of hospital work.
The following table showing the relative percentage of the total
expenses for each of the eight principal items of hospital operation, in
a group of seven hospitals recently studied in New York City, is here-
with presented as an indication of the precentage analyses which are
possible when the needed facts are available:
Services for the Sick
Percentage Distribution of Expenditures by Eight Principal Items
(Seven Hospitals — New York City)
No. 1 . . .
It is evident that the effective use of such large and active invest-
ments requires careful financial planning, including budgetary methods
and modern cost accounting — in other words those financial policies and
practices that are endorsed as sound and reasonable for the conduct of
public trusts generally.
The chief defect of the financial operation is the almost general
absence of these evidences of financial planning. For example, although
some of the hospitals, notably the University of California and Mount
Zion Hospitals, make some use of budgetary methods, the information
obtained indicates that, at the first named, departmental and general per
capita costs do not enter largely into budget consideration and at the
latter, that but three of the departments are operated on budgets.
In hospital operation an adequate financial plan includes the deter-
mination of an annual budget for each department based on its past
performance, use and needs, and the co-ordination of these departmental
budgets in a combined budget for the institution as a whole. It includes
also consideration of the expenditure of funds for the purchase of new
equipment, education of personnel, new activities, etc., as well as those
for the routine operation of the institution.
In order to make and carry out a comprehensive and effective financial
plan it is necessary for each managing board to consider departmental
reports of work done, monthly statements of receipts and expenditures,
current departmental and per capita operating costs, and a comparative
budget and expense statement. Although the hospital boards receive
monthly financial reports, many of them showing departmental receipts
and expenditures, these are not associated with analyses or records of
work done and even in those institutions where they have been established,
cost units do not appear to be reviewed.
The work of the Survey included the collection of only general
facts regarding accounting methods and financial policies.
It is recognized that there necessarily enter into the operation < of
the University of California and Lane and Stanford University Hospitals
74 Hospital and Health Survey
complex questions of cost distribution, in order to determine hospital
operating costs as differentiated from medical school operating costs.
These costs are somewhat segregated at Lane and Stanford University
and are now undergoing analysis and revision at the University of Cali-
fornia, although general facts gathered at the latter suggest that as yet
there has been no separation of the cost of private room patients and
ward patients, and that the accounting system does not readily furnish
unit per capita costs.
Based on the facts ascertained, it is evident that the accounting
systems of the majority of the hospitals are in general of the type
considered satisfactory some years ago, but unsuited to many phases of
present day hospital operation.
All of the defects encountered are not common to each institution
but there were sufficient evidences to indicate that among the deficiencies
are, the lack of periodic audits, modern inventory methods, and operation
on a cash rather than an accrual system. Some of the hospitals have
their books audited regularly by certified public accountants. Others have
excellent stores and inventory methods and in still others an accrual
system is in effect.
The varying methods of estimating free service in the different
institutions further indicate the need for the introduction of modern cost
methods. This is illustrated in the fact that more than one hospital bases
the cash value of its free service on prices charged and not on cost.
Thus, in one hospital, if a free patient, because of his condition, is placed
in a separate room, the free work of the institution is credited with the
scheduled price of the room, and not the cost of hospital maintenance ;
conversely, when ward care for which $2.50 a day is charged is given
free, the hospitals free work is credited with this amount instead of
the actual per' capita cost, which is over $4. In another of the hospitals,
laboratory examinations furnished free are listed in the hospital's free
work at scheduled prices instead of at cost. It must be clear that if a
room costing $4 a day to maintain is listed at $6 work of free service,
or if laboratory examinations costing $1 are listed at $3 worth of free
work, entirely fallacious totals are built up, bearing no relation to the
actual cost of the free service furnished. We cannot give away some-
thing we do not possess and we cannot give away $6 worth of care that
costs but $4, nor $3 worth of laboratory service that costs but $1. The
consensus of lay opinion would certainly be to the effect that public con-
tributions for hospital care are made in order that free treatment will be
available to those unable to pay the cost of hospital service, and that the
only charge to the free account for that service which is rendered free,
should be the actual cost to the hospital of such service.
Probably the most general defect is that accounts are not kept
with a view to careful self-analysis as to cost of work done, essentials
of which are the cost of hospital operation as a whole, the cost of the
operation of the different departments, and the unit costs of the various
types of service. This information is essential in determining expendi-
Services for the Sick 75
tures, allocating waste, setting rates, measuring efficiency, and for purposes
of comparison with other institutions conducting similar work.
Of the unit costs, the one most important and generally most used,
is the per capita per diem cost — the amount representing the average
daily cost of caring" for one patient. Deductions based on this cost,
to be of value, should be correlated with facts regarding hospital opera-
tion, whether, for instance, a low per capita cost is due to poor equipment,
many chronic patients, undue crowding, etc., or conversely, whether a
high per capita cost is due to a low degree of use of the hospital's beds,
to the maintenance of costly diagnostic and treatment facilities, to un-
economical administration, etc.
The per capita per diem costs herewith presented were furnished
by the institutions, with the exception of St. Mary's and the French
Hospitals, in which cases the costs were estimated by the Survey on the
basis of the total number of days' care compared with the total cost of
operation, this cost at the latter institution including expenditures for
both the Society and the hospital. ,
In presenting these cost data, it should be understood that in many
instances they represent a blanket cost for both private and ward patients,
for which the facilities, services, and maintenance vary considerably.
For example, when a hospital states that the per capita cost of its bed
care is $5 or $6 a day for all patients, it does not mean that $5 or $6 a
day is expended to maintain all classes of patients, whether in the wards
or in private rooms. What it does mean is that patients paying high
rates and receiving increased service, superior surroundings and more
expensive foods, raise the average cost for the care of ward and
semi-private patients for whom comparable provisions are not furnished,
and does not represent the true cost of care given to the majority of
free and part-pay patients.
Hospital and Health Survey
The individual per capita per diem costs of the nine hospitals during
1 ( )22, were as follows:
Per Capita Per
Hospitals Diem Costs
Children's Hospital $4.77 -
Franklin Hospital 4.86
French Hospital 4.46
Lane and Stanford University Hospital 4.85
Mary's Help Hospital 4.08
Mount Zion Hospital 7.04
St. Luke's Hospital 6.74
St. Mary's Hospital 4.43
University of California Hospital 4.16
These data, which show a wide range in the cost of hospital care, are
pictured in Chart D, page 77 .
In view of the fact that there is considerable sentiment in San
Francisco to the effect that the prices charged for bed care, laboratory
services, and for special treatments, are in general high and provide
small opportunity for hospitalization, diagnosis and treatment at moderate
rates, information was collected relative to the current rates for children,
adults and maternity patients and for laboratory examinations.
It is believed that more complete facts might modify the figures
derived from the information furnished, shown in the following table,
but they represent a summary of the information as obtained from the
hospitals on direct inquiry :
Beds for Children (Medical and Surgical Conditions)
Number of Beds Per Cent
Under $2 a day
$2 to $3 a day 114 .58 58
$3 to $4 a day 23 12
$4 to $5 a day 55 28
Over $5 a day 2 2 42
Beds for Adults (Medical and Surgical Conditions)
Number of Beds Per Cent
Under $2 a day
$2 to $3 a day 15 1
$3 to $4 a day 392 28 29
$4 to $5 a day 420 30
$5 to $10 a day 556 40
Over $10 10 1 71
Beds for Maternity Patients
Under $3 a day
$3 to $4 a day S3 23
$4 to $5 a day 50 34 57
$5 to $10 61 43 43
I s -*
I s -
1 jg c
— 1 c
78 Hospital and Health Survey
While these facilities show a high percentage of accommodations at
more than moderate rates — only about one-fourth of the facilities being
offered at prices ranging from $21 to $28 a week — actually in practice
these are at times waived to accommodate patients who cannot afford to
pay the full cost of the scheduled rates. Many of the hospitals -allow
discounts on bed care, laboratory examinations, special treatments, etc.,
some of these discounts being generous. Several patients visited during
the course of the convalescent study of the Survey had not paid in full
for their care, either for their ward or room beds, or for special and
extensive diagnostic and treatment services required by their condition.
P>ased upon the brief material available for study, it is evident that
some adjustment in the rates is needed in order to serve equally all the
economic groups of the population. The specific provisions which should
be made can only be determined by a co-ordinated study on the part
of the hospitals. The Survey has insufficient knowledge upon which to
base conclusions of value except that, in view of the preponderance of
facilities costing over $4 and $5 a day and the difficulty experienced
by physicians and interested lay workers in hospitalizing part-pay patients,
a further detailed study of the subject by the hospitals themselves appears
One of the matters receiving attention from hospital authorities is
the regulation of fees for laboratory examinations. The practice of charg-
ing a separate fee for each examination is being discontinued and a flat
fee to cover all pathological laboratory work is being substituted. This
substitution has been introduced at the University of California, Mount
Zion, and St. Mary's Hospitals.
More recently leading hospital administrators are regarding the cost
of laboratory work as a general hospital expense and discontinuing the
charging of special and separate fees. In order that the cost of operating
the laboratory department shall be met, the actual cost of maintaining
the department is divided by the number of days of care furnished, the
resulting small amount being added to the existing room or ward rate.
Thus, a hospital may find that the total cost of its pathological
laboratory, when spread over the total days of care, increases the cost
by 25 cents per patient day. Rooms that were $4 a day are thus raised
to $4.25 a day and no separate item for laboratory examinations appears
on patients' bills. (Mount Sinai Hospital, Cleveland, an institution operat-
ing extensive laboratory departments, estimates the cost of its pathological
laboratory at 16 cents per patient day.)
Similar methods for apportioning the cost of X-ray examinations
have been adopted to only a small extent, although recognized as correct
in principle. The amount which will be required to meet the cost of a
hospital's X-ray department can be fairly well determined by predicating
cost and volume of work upon the last six months' or years' experience
of the department's activities and cost of operation.
Services for the Sick
"Hospital operation at present shows similar instances of cost dis-
tribution. Thus, no separate charge is made for the services of a dietitian,
although the treatment of individual patients frequently requires con-
siderable time and attention from dietary departments. Again, hospitals
make no charge for the services furnished by social service departments,
although these also are available and used for other than free patients.
There is no apparent reason why a patient should pay for an examination
of his blood, which is one phase of hospital service, any more than for
the services of a dietitian, or of a social service worker.
It must be obvious that the determination of the amount which should
be added to the daily rate to cover laboratory costs when distributed as
a general cost, can only be undertaken when the individual operating costs
of laboratory departments are known.
Even a brief review of the laboratory rates now charged in the nine
hospitals indicates that some are out of all proportion to the cost and are
comparable to those charged in commercial laboratories which naturally
expect to make a good profit. Thus a rate of $5 for a Wassermann test —
an examination which costs from 20 cents to 30 cents in a well-managed
laboratory — is excessive. In X-ray departments likewise, in many in-
stances, the prices charged are not based on cost, even for dispensary
patients. For example, the price charged for an X-ray examination of
a hand, arm or finger — $5 to $10 in some of the hospitals — shows a con-
siderable margin of profit. This is also true regarding X-ray examinations
of teeth, the price varying from $5 for complete X-ray with $1 for one
tooth, to $15 for complete X-ray, with $2.50 for one tooth.
The adoption of a policy of "no extras" on patients' bills for these
scientific examinations is desirable and should be agreed to. San Fran-
cisco hospitals have here an opportunity to crystallize hospital opinion
by the adoption of a program which will provide examinations and treat-
ments upon a basis of diagnostic and therapeutic necessity, rather than on
an arbitrarily determined economic basis.
It is clear that these ten hospitals, founded upon definite needs in
the community life, constitute a dominant factor in the work of the city
for the care of the sick. Their boards and staffs are responsible for the
medical standards surrounding the care of at least three-quarters of the
city's sick who enter hospitals and over 90 per cent of those who receive
This intimate contact with thousands of the population ofifers enviable
opportunities for the care of the sick, the prevention of sickness and the
promotion of health, matters which the progress of medicine renders
yearly of increasing importance. Institutions which, like these ten hos-
pitals, are spending millions of dollars annually for such purposes, need
not only managing boards which concern themselves with the details of
administering particular institutions, but also a central body free to think
out those broader policies which will increase the efficiency of health and
80 Hospital and Heai/th Survey
medical work throughout the community and enable every dollar to
bring the greatest return.
In the opinion of the Survey, the chief lack in the San Francisco
hospital field is the absence of contact among the individual units of
this large community undertaking. The institutions, with common aims
of public service, have no unifying organization or program for the.
effective accomplishment of the work in which they are each individually
engaged, nor is there a central authoritative group equipped to study
particular problems and plan for their solution.
There is needed a well-organized co-operative group which could
formulate general standards, suggest policies and determine programs for
dealing with the particular problems of the hospitals of San Francisco.
The need for some plan for co-operation is appreciated. The general
sentiment among hospital boards and executives favors a commonsense
working basis for the co-ordination of hospital policy and of certain
aspects of hospital administration, the elimination of known duplications
and wastes and for the mutual benefit which would result from unified
effort and joint planning.
The success of joint councils suggests that the hospitals would derive
benefits and stimulus from the establishment of a Hospital Council — in
fact every indication for progress points toward the advisability and
practicability of such a co-operative effort.
A Hospital Council, properly organized, would leave undisturbed the
executive powers of the individual hospitals, and provide a central ad-
visory and co-operative service; the Council to serve primarily as a
volunteer organization for the development of improved hospital service
and economy of hospital operation, to enjoy delegated powers only, and
to influence hospital affairs through the confidence which it inspires
and the authority thus established.
Such a Council should include representatives of the boards and the
executives of all the hospitals of the city and men and women from pro-
fessional and business groups, as follows:
(a) One member from the board of each hospital.
(b) The hospital executives.
(c) Additional members at large to include preferably a representa-
tive of the County Medical Society, a lawyer, a financier, an accountant,
a representative of the Council of Social Agencies and several women of
broad interests, one of them, preferably, an educator.
Such an organization would enable the experience of each institution
to be of benefit to all and would break down the tendency to isolation
which is characteristic of institutions without a central co-ordinating
Services for the Sick 81
To be effective, the Council should organize with officers and com-
mittees, and provide for at least monthly meetings. The more important
standing committees should be appointed, and provision made for the
appointment as needed of special advisory or study committees with extra-
In order to accomplish results and obtain the fullest advantage
accruing from co-ordinated effort and pooled experience, it is essential
that the Council employ an ably equipped, whole-time executive secretary.
The initial Council activity which could be undertaken with advantage,
and which would render immediate services to the hospitals is a central
The experience of the Cleveland Hospital Council is indicative of
the large benefits accompanying the establishment of such a co-operative
service. During 1922 over $700,000 was expended by its purchasing
bureau, with great saving to the hospitals and other institutions, and
much improvement of service in the matter of deliveries, etc.
Not the least important use of a centralized purchasing system is
the expert advisory service made available for studying market conditions,
It would probably be necessary to establish an initial revolving fund
so that cash discounts might be taken. The saving thus effected would,
for the eight private hospitals alone, be considerable. During 1922, less
than $1000 was thus earned, although experience demonstrates that cash
discounts will equal one-half of one per cent of the total expenditures of
hospital operations — an amount in the eight hospitals of approximately
In addition the following problems, regarding which there already
exists considerable knowledge and opinion, warrant early group attention :
(a) There is need for the establishment of uniform standards for
reporting those medical administrative and financial statistics recognized
as essential as a basis for guiding medical, financial and administrative
policies. The monthly report form adopted by the Cleveland Hospital
Council for reporting similar facts to the Cleveland Welfare Federation
appended to this report (see page 145, Section V) gives the items which
should be collected.
(b) A study of hospital rates, with special reference to the needs
of families of moderate means, correlated with facts as to part-pay patients
admitted and those applying and not admitted, all assembled uniformly
by all' the hospitals would furnish a basis upon which to determine
the provision which must be made.
In this connection, consideration should be given to the question
of the establishment of part pay facilities at the San Francisco Hospital,
as furnished by municipal hospitals in other cities — notably Bellevue
Hospital, New York City, and the Buffalo General Hospital, Buffalo, N. Y.
(c) There is need for more complete information regarding the
82 Hospital and Health Survey
problems of the chronically sick. The collection of facts on this subject
over a considerable period would provide a basis for determining the
extent of the need and for suggesting a program to meet it.
(d) The economy of a central collection service to which unpaid
hospital accounts could be turned over for collection is a subject requiring
particular study. A similar service instituted two years ago by the
Cleveland Hospital Council 7 has four main objects: "1. Collect 'col-
lectable' accounts at the lowest cost. 2. Prevent 'Current' accounts from
becoming 'dead' accounts and reduce to a minimum amounts charged
off as 'accounts uncollectable.' 3. Fix the status of every account within
six months as 'collectable/ 'uncollectable' or 'collected.' 4. Reduce
amounts to be charged off to a minimum every six months."
(e) The question of obtaining recruits for the schools of nursing
is a problem in almost every one of the hospitals. This important sub-
ject deserves the attention of a special committee or a permanent sub-
committee, representative of all the training schools and various profes-
sional nursing groups. It would naturally concern itself with such matters
as the formulation of a program to reach high schools, normal schools,
and women's colleges, direct attention to the excellencies and special
opportunities of the various schools and would be effective in focusing
attention on questions of group instruction during the preliminary period,
need for opportunity in visiting nursing, the non-educational and non-
nursing work now performed by student nurses in the hospitals, and the
need for practical experience now lacking, such as medical social service,
communicable disease nursing, including tuberculosis and venereal dis-
(f) The question of hospital personnel, the ratio of personnel to
patients, the establishment of standards for salaries, wages, hours of work,
and provisions for initial and periodic health examinations of hospital
workers in order that the sick will be surrounded only by the well, are
matters which would benefit through persistent study.
(g) Co-operative relationships should be established with the leaders
in the Chinese health movement in San Francisco, with particular refer-
ence to the plans now developing for a hospital and dispensary for the
Chinese, under Chinese direction and control.
(h) Benefit would result from collective attention to matters of
hospital administration. There are at present unsolved problems which
need careful consideration. The publication of annual reports, member-
ship in national associations, attendance at national conferences and meet-
ings of hospital executives and department heads, departmental organiza-
tion, reports of work done, personnel, salvage, sale of materials, the use
of labor-saving devices, etc., stores procedures, repair of surgical equip-
ment and appliances, and similar subjects, are all worthy of study in the
interest of hospital economy and good public service.
7 The Cleveland Hospital and Health Survey — Two Years After. Cleveland Hospital
Services for the Sick 83
The organized dispensary service of the city is furnished by nine
institutions, six of them hospital out-patient departments and three of
them independent organizations :
University of California Hospital.
Lane and Stanford University Hospital
Mary's Help Hospital.
Mount Zion Hospital.
St. Luke's Hospital.
San Francisco Polyclinic.
San Francisco Neighborhood Association, conducting the dispensary com-
monly called Telegraph Hill.
In addition to the foregoing, occasional clinic sessions for general
and special patient groups are conducted by St. Mary's and the San
Francisco Hospitals, and consultation or treatment hours are held at
regular times by the Franklin and French Hospitals, Although these
four institutions have at their command the supplementary services re-
quired for adequate medical care, they cannot properly be classed as
affording dispensary service in the present day meaning of the term.
The Osteopathic Clinic, lacking adequate provision for diagnosis and
treatment, is not here included.
The dispensary facilities at these nine institutions are indicated by
the number of clinic sessions held weekly and the number of hours of
service offered. The number of clinic sessions held weekly during
the morning, afternoon and evening hours, are as follows :
84 Hospital and Health Survey
Dispensary Facilities of San Francisco
Number of Clinic Sessions Weekly
Total Morning Afternoon Evening
Sessions Sessions Sessions Sessions
Public Institutions —
University of California 129 87 36 6
Privately Controlled Institutions —
Children's 48 42 6
Lane and Stanford University 67 54 12 1
Mary's Help 57 57
Mount Zion 73 67 6
St. Luke's 50 41 9
Totals 295 261 33 1
Homeopathic 28 27 1
Polyclinic 51 51
Telegraph Hill 21 2 19
Totals IOC 80 20
Grand Totals 524 428 89 7
The foregoing table does not include the following: (a) the morn-
ing, afternoon and evening office hours held by salaried physicians of the
Franklin and French Hospitals, chiefly for members of the mutual benefit
associations conducting the two hospitals; (b) the Orthopedic Clinic con-
ducted by St. Mary's Hospital three mornings weekly; and (c) the five
morning and one evening Chest Clinics and the one afternoon Prenatal
Clinic held at the San Francisco Hospital weekly.
The scheduled number of hours weekly, represented by the 524
clinic sessions, are shown in the following table :
Services for the Sick 85
Dispensary Facilities of San Francisco
Number of Clinic Hours Weekly
Total Morning Afternoon Evening
Hours Hours Hours Hours
No. Pet. No. Pet. No. Pet. No. Pet.
Public Institutions —
University of California 336 27 258 25 72 38 6 75
Privately Controlled Institutions —
Children's 78 6 60 6 18 10
Lane and Stanford University 196 16 172 17 22 12 2 25
Marv's Help 171 14 171 17
Mount Zion 208 17 197 19 11 6
St. Luke's 81 7 69 6 12 6
Total 734 60 669 65 63 34 2 25
Homeopathic ' 45 3 44 4.5 1 .5
Polyclinic 56 5 56 5
Telegraph Hill 56 5 4 .5 52 27.5 ..
Total 157 13 104 10 53 28
Grand Total 1227 100 1031 100 188 100 8 100
86 Hospital and Health Survey
As 91 per cent of the clinic sessions shown in the preceding table
are scheduled for the working hours of the day, they afford small oppor-
tunity for dispensary care in the free time of wage earning groups, one
of the groups for which dispensary service is chiefly maintained.
The concentration of the clinic sessions in the morning hours, pic-
tured in Chart E, page 87, represents a considerable unused investment
in dispensary space and equipment. It will be seen that, although some of
the institutions use their plants for a few afternoon clinics, practically no
use is made of them during the evening.
The number of physician-hours of service actually provided per
100,000 of population — the correct basis for estimating hours of dis-
pensary service — is not possible until physicians' registries are used
uniformly in each institution. With such facts available, analyses can
be made by the individual dispensaries of the amount of physicians' time
devoted to original and return patients.
MEDICAL SERVICES PROVIDED
From the standpoint of medical care, the character and type of
medical services offered are reflected in the facilities provided for general
and special patient groups, and the number of hours available for each
group. These facts are shown in the accompanying table :
Oi cvi o
M> o o
HoSPITAIv AND HeAI/TH SURVEY
Weekly Hours of Dispensary Services to Patient Groups
Hospital Dispensaries ^
Public Privately Controlled
A. M. . . ,
P. M. ...
Eye, Ear, Nose and
P. M. . . .
A. M. ...
12 10 106
.. 2 14
18 18 18 12 90
.. .. .. 2 14
18 18 18 6 78 10
36 10 124
. . 2 27
18 1 18
18 15 27 18 10 88
> • • •
i • • •
• • • . •
258 60 172 171
72 18 22 ..
6 . . 2
194 69 924
14 12 138
2 .. 8
18 12 22 19 20 11 101 4 6 2
12 3 3 22 .... 14
44 56 4
1 .. 52
>^s Oj CS) C\J > o o
< ro i*> ro
Ci M* CO
N. *^ <^ C\J ^>
oo O K
<: ro <
<3 ^ <0
o o JS
90 Hospital and Heai/th Survey
The foregoing facts, also pictured in Chart F, page 89, not only
emphasize the preponderance of morning clinic sessions and the meager
provisions for afternoon and evening dispensary care, but also show
that the provisions other than those available in the morning, are only
for special patient groups.
The range of general and special patient groups for which provision
is made, indicates that dispensary service in San Francisco is well
developed for the general services and, to a considerable degree for
the more special services, but that there is need for further development of
facilities for the supervision of pregnant women, patients with heart dis-
ease, and those with venereal diseases.
There should be some facilities for evening clinics for the benefit
of persons with venereal diseases, cardiac patients, and for certain other
patient groups who work. This would not necessitate having elaborate
equipment, but would serve as a means of helping people improve in
health by having a place where they could obtain medical care and
treatment at cost, after working hours.
Certain of the special clinics reflect commendable increasing hospital
participation in sickness prevention and community health affairs. Among
them might be mentioned the Posture Class at Lane and Stanford Uni-
versity, the Well Baby Clinics at Telegraph Hill, Lane and Stanford
University and Mount Zion, the Chest Clinics maintained by the Board
of Health at the University of California, Telegraph Hill, Lane and Stan-
ford University and Mount Zion, those for Orthodontia at Mary's Help,
the clinics for school children held at Mount Zion, etc. Another develop-
ment thoroughly in accord with modern health service, is the Health
Examination Clinic for Adults at the University of California, now in
process of formation.
The lack of reciprocal medical records of patients referred from
some of the hospitals to their out-patient departments or to independent
dispensaries interferes with the continuity of medical care and hampers
social follow-up of patients. The results of this lack are illustrated by the
following case :
Case No. 18 — A six and a half months' old baby in the hospital for two
weeks with tonsillitis, otitis media, cystitis and cervical adenitis, was discharged
as cured, the mother being told to take the child to an independent dispensary
in her neighborhood so that a urine examination could be made weekly. The dis-
pensary had received a telephone message from the hospital stating the patient
had been discharged, but no medical history, diagnosis, treatment or notes as to
further care were forwarded from the hospital. When the mother took the baby
to the dispensary, she was referred to the well-baby clinic. As the physician
in this clinic took up the matter of diet and weight and asked no questions
which would have brought out the hospital history, nothing was known about
the conditions for which the patient had been treated, or the further care ordered
by the hospital doctor. The dispensary is not equipped to make urine exami-
Similarly, patients under dispensary supervision for long periods may
be sent to hospitals for bed care without any advantage accruing to either
the patients or the hospital doctors from the accumulated clinic expe-
Services for the Sick
rience, due to the fact that the medical records of clinic care do not
always accompany patients to hospitals.
The foregoing defects are noticeable omissions in the medical care
provided for patients admitted to the San Francisco Hospital who also
attend the out-patient departments of the two university hospitals. These
two hospitals have excellent reciprocal records for their own in and out-
patient departments, but similar standards of medical supervision have not
been instituted for their patients who are treated at the San "Francisco
ORGANIZATION AND EXECUTIVE CONTROL
But two of the hospital dispensaries, the out-patient departments of
Mary's Help and the University of California Hospital, approach, in
organization and executive direction, the standards advocated for modern
dispensary operation. At these institutions, most of the functions of man-
agement of the dispensaries are centered in one individual whose chief
responsibility is the direction of the department.
At Lane and Stanford University the out-patient department is a
department of the Medical School, and there is no one person charged with
its management and giving it his main attention.
At Mount Zion and Children's Hospitals, although the dispensaries
are hospital departments, direction is not centered in individuals responsi-
ble alone for the operation of the departments. As pointed out in the.
chapter on Social Service, the work of the social service departments of
these two hospitals is obscured by the dispensary executive responsibilities
Of the independent dispensaries, the Board of Trustees of the Poly-
clinic is composed entirely of physicians, an arrangement and in accord
with approved standards of board organization. The administrative organ-
ization is also not in agreement with the accepted principles of dispensary
management, and does not furnish a basis for segregating dispensary costs
as differentiated from those expenditures which relate essentially to the
operation of its twelve-bed hospital unit, maintained chiefly for private
At Telegraph Hill Dispensary, an activity of the San Francisco
Neighborhood Association and managed by its Board of Directors, the
executive control of the clinics appears to be carried in part by a member
of the board, and in part by a member of the salaried personnel.
In view of the limited service of the Homeopathic Clinic and its small
salaried staff, the principles of organization and management applicable to
the other dispensaries do not appear to apply.
Dispensary committees of directing boards — advocated in hospital
operation as a practical means of dealing with dispensary problems — are
undeveloped, Mount Zion Hospital alone having a functioning dispensary
92 Hospital and Health Survey
It is evident that in the dispensary field, as in the hospital field, there
is need for a general community plan to provide for the special economic
and sickness groups to be served. A dispensary committee of the proposed
Hospital Council, representing all the organized dispensary groups, would
be an effective body to study the particular needs of the city's ambulatory
sick, and formulate a program which would co-ordinate the various phases
of the work now operating in unrelated units.
SERVICES RENDERED BY DISPENSARIES
In studying the extent of the dispensary service rendered, the main
facts considered consisted of (a) the total number of visits for 1922,
together with similar data for 1921; (b) the number of new patients
applying in two representative months, November, 1922, and January,
1923, and (c) the geographical districts served by the individual dis-
pensaries, based on an analysis of the addresses of 5632 patients apply-
ing at the nine dispensaries and the clinics of the San Francisco Hospital
during the two foregoing months.
(a) DISPENSARY ATTENDANCE— 1922
During 1922, a total of 272,000 visits were made to the nine dis-
pensaries, as follows :
Dispensary Attendance — 1922
Number of Per Cent Gain or Loss
Visits of Total 1921-1922
Public Institutions —
University of California 90,343 33 +1
Privately Controlled Institutions —
Children's 12,998 5 +2
Lane and Stanford University 96,845 36 +12
Mary's Help 11,749 4 +13
Mount Zion 28,520 11 +14
*St. Luke's : 11,281 4 + 54**
Total 161,393 60
Homeopathic 1,664 1
Polyclinic 10,419 3 +37
Telegraph Hill 8,181 3 —32
Total 20,264 7 — 5
Grand Total 272,000 100 + 7
♦Number of visits at St. Luke's includes 5332 visits to Canon Kip Memorial Clinic.
♦♦Attendance at Canon Kip Memorial Clinic not included.
Services for the Sick
Based upon the foregoing data, the total number of visits to the organ-
ized dispensaries during 1922 indicate a ratio of about fifty visits per hun-
dred of population. As the study of the addresses of the new patients
indicated that 11 per cent were non-residents, (shown later in this chap-
ter), the actual ratio for the city's population would more nearly approach
forty-four visits per hundred.
Comparison of this ratio with the ratios for other large cities is of
Ratio of Dispensary Visits to Population
New York City (1919) ' 60 per 100
Chicago (1918) 35 per 100
Greater Boston (1919) 50 per 100
Cleveland (1921) 26 per 100
Montreal (1921) 45 per 100
San Francisco (1922) 44 per 100
94 Hospital and Heai/th Survey
Using the estimate adopted by dispensary authorities — four visits per
patient — it is assumed that some 68,000 persons sought dispensary care,
about 60,500 of them being residents of the city.
The percentage of total visits received by the individual dispensary,
pictured in Chart G, page 95, indicates the importance of the services
contributed by the two university dispensaries, the combined visits to these
two institutions representing 70 per cent of the total dispensary attendance
of the city for the year. Mount Zion received 11 per cent of the total
visits, the other institutions, respectively, 5 per cent or less.
J5 :§ z:
96 Hospital and Heai/th Survey
The 90,000 visits made to the one publicly maintained dispensary indi-
cate a ratio of 16 per 100 population. The dispensaries under city and
State auspices in Buffalo, a city of similar size — 650,000 population — dur-
ing 1922 received 192,213 visits, a ratio of 29 visits per 100 population.
A tabulation of the monthly attendance at the six hospital dispen-
saries, for the year 1922, indicated only slight seasonal variations in
attendance, with the exception of a marked decrease in the number of
visits during the month of February. These facts are shown in Chart H,
98 Hospital and Health Survey
The table of attendance also shows the percentage of increase or
decrease in visits for the individual dispensaries, compared with similar
data for 1921. The total number of visits for the nine dispensaries
showed an increase of 7 per cent. Individual dispensaries showed much
higher percentages of increase, St. Luke's having an increase of 54 per
cent and Polyclinic 37 per cent; the only dispensary showing a decrease
being Telegraph Hill, at which the attendance fell off 32 per cent during
(b) NEW DISPENSARY PATIENTS— TWO REPRESENTATIVE
As the number of new patients using a dispensary is one index of the
extent to which it is used, tabulations were made of the addresses of the
new patients who applied to the nine dispensaries and the clinics main-
tained at the San Francisco Hospital during November, 1922, and January,
1923, two months considered by local groups to be representative of the
maximum monthly demand. This tabulation showed that during these two
months 5632 new patients applied for dispensary care, as follows :
New Dispensary Patients — November, 1922, and January, 1923
Number Per Cent
Public Institutions —
San Francisco 249 5
University of California 1712 30
Total • • 1961 35
Privately Controlled Institutions —
Children's 340 6
Lane and Stanford University 1920 34
Mary's Help 301 5
Mount Zion 342 7
St. Luke's •-.. 196 3
Total 3099 55
Homeopathic 49 1
Polyclinic 257 4
Telegraph Hill 266 5
Total V 572 10
Grand Total 5632 100
The University of California Hospital and the Chest and Prenatal
Clinics at the San Francisco Hospital thus received 35 per cent of the
new patients during the two months studied. The privately controlled dis-
Services for the Sick 99
pensaries received all told 65 per cent of the new patients, of which the
five hospitals maintaining out-patient departments received 55 per cent, and
the independent dispensaries 10 per cent.
(c) AREAS SERVED BY DISPENSARIES
The study made of the home addresses of the 5632 new patients was
designed to ascertain two important facts,, namely, the extent to which the
dispensaries are used by residents and non-residents of the city, and the
areas served by each dispensary.
The extent to which the dispensaries serve San Francisco is clearly
indicated by the fact that, during the two months analyzed, 89 per cent of
the new patients were residents of the city, and but 11 per cent non-
residents. As shown in the following table, the Homeopathic and the Tele-
graph Hill Dispensaries received no new patients from out of the city, the
University of California Dispensary having the highest percentage of non-
residents, 20 per cent of the total. As the last-named is a State institution,
it is to be expected that there is at all times a certain percentage of non-
resident patients applying for care.
Percentage of City Residents
New Dispensary Patients, November, 1922, and January, 1923
New Patients Per Cent from
Public Institutions —
San Francisco ■ 249 97
University of California 1712 80
Total 1961 82
Privately Controlled Institutions —
Children's 340 92
Lane and Stanford University 1920 91
Mary's Help 301 98
Mount Zion 342 96
St. Luke's 196 99
Total 3099 93
Homeopathic 49 100
Polyclinic 257 93
Telegraph Hill 266 100
Total 572 97
Grand Total 5632 89
If the experience of the two months is typical of the usual situation,
there is need for a redistribution of the clinic facilities of the city, so
that special or acceptable clinic care will be readily accessible to the eco-
nomic groups for which dispensaries are primarily established.
100 Hospital and Health Survey
The present situation is indicated in Map 3, page 101, which shows
the large percentage of dispensary patients from the Potrero and Inner
Mission districts who traveled long distances to obtain the dispensary care
they desired. Thus, only 28 per cent of the 1738 patients went to clinics
within the two districts, 60 per cent going to the University of California
and Lane and Stanford out-patient departments, the remaining 12 per
rent attending the four other dispensaries located on the north side of
An analysis of the attendance at the nine dispensaries is of interest
as showing the general areas served by the several institutions:
University of California Hospital — Compared with the degree to which
it draws patients from other sections of the city, this dispensary serves its
own neighborhood to only a small extent. Patients are drawn in large
numbers from distant sections ; thus, Telegraph Hill, the neighborhood of
St. Luke's and San Francisco Hospitals and downtown sections extending
from Eighth to Second streets, furnished a large volume of the patients.
San Francisco Hospital — While the majority of the new patients
attending the hospital's Tuberculosis and Prenatal Clinics came from the
nearby locality, it is of interest that a considerable number came from dis-
tant sections of the city, notably Telegraph Hill, where the Neighborhood
Association maintains one of the Board of Health Chest Clinics and a
Prenatal Clinic, and from the neighborhood of Mount Zion Hospital,
which also maintains a Chest Clinic and a Prenatal Clinic, and from the
vicinity of St. Luke's, which has no tuberculosis clinic facilities or special
service for pregnant women.
Children's Hospital — As the chief center for care of sick children, the
dispensary draws patients from nearly every section of the city, with an
increased number coming from the Potrero and Sunset districts, and the
largest number from the immediate vicinity of the hospital and from the
Telegraph Hill district.
Homeopathic Clinic — The new attendance at the Homeopathic Clinic,
thirty-nine in all, was too small to be of value. It is significant, however,
that one-third of the total new patients admitted during the two months
came from the Deaconess Home, which adjoins the dispensary and with
which it is loosely affiliated.
Lane and Stanford University Hospital — -In addition to a rather gen-
eral distribution of patients throughout the older sections of the city, the
dispensary serves definite districts, large numbers of patients coming from
the sections north of Market street, the district bounded by Eighth, Chan-
nel, Market, and Second streets, and from the near neighborhood of the
Mary's Help Hospital — Mary's Help dispensary is furnishing care pri-
marily to its own district, a maximum number of new cases coming from
the immediate neighborhood of the hospital.
Mount Zion Hospital Dispensary — The dispensary maintained at
Mount Zion also shows a fairly well-defined neighborhood service as,
r^ ^ ^
102 Hospital and Health Survey
except for a few scattered patients in other sections of the city, the new
patients came from the immediate vicinity of the hospital and the section
bounded by Market, Larkin, Geary, and Fillmore streets.
Although no study was made of the area served by San Bruno Health
Center, it was understood that the service is primarily to residents of the
St. Luke's Hospital — The area served by St. Luke's is largely confined
to the immediate vicinity of the hospital, only occasional patients coming
from other districts. This is particularly of interest in view of the hospi-
tal's endeavor to establish the dispensary as a health center for its neigh-
borhood. No study was made of the area served by the Canon Kip
San Francisco Polyclinic — Based upon the addresses of the two
months, the Polyclinic's new patients came from the scattered sections all
over the city, with a concentration of cases from its own neighborhood and
that of Telegraph Hill.
Telegraph Hill Dispensary — This dispensary, the undertaking of a
neighborhood settlement, shows the highest percentage of neighborhood ser-
vice, 96 per cent of the new patients coming from its immediate sur-
Due to the recent rapid growth in dispensary service and attendance,
there is throughout the country a general inadequacy of physical facilities
for dispensary care.
In San Francisco, as in other large cities, few of the dispensaries are
suited either in original plant or arrangement of space, to meet the
demands of modern dispensary operation.
At Mount Zion the dispensary department is housed in a building of
comparatively recent construction, planned for the purpose and well-
equipped, but its operation is handicapped by overcrowding. The Poly-
clinic building, while planned for dispensary purposes, lacks essentials in
arrangement of space, convenience of facilities, and needs additional equip-
ment to facilitate the work.
The dispensary departments of the University of California and Lane
and Stanford University Hospitals, notwithstanding much special equip-
ment and many unusual facilities, are conducted under physical handicaps,
the latter especially presenting a picture of compromise arrangements,
insufficient space, and awkward working conditions.
The quarters at Mary's Help, Children's, and St. Luke's Hospitals
do not provide essentials as to space and arrangement. Mary's Help
appears to need additional equipment for special services, the dental facili-
ties being a striking exception. Children's, while excellent in equipment
and ingenious in use of space, is conducted in limited and unsuitable quar-
ters. St. Luke's operates under hampering physical conditions, likewise
Services for the Sick
Telegraph Hill, although a resourceful use of space at the latter lessens
the obvious inadequacies of the original plant. .
The method of operation in effect in practically all of the dispensaries,
with from 77 to 100 per cent of the scheduled sessions occurring in a few
hours of the day, emphasizes the original physical defects.
From a community service viewpoint, the chief defects of the dispen-
saries — prolonged waiting and overcrowded clinics — result from this fact.
It should be stated that in no instance was prolonged waiting for clinic
treatment regarded by the dispensary workers interviewed as a defect of
service. A two-hour wait was stated to be common, and was viewed as a
natural phase of dispensary operation.
In particular, recognition should be given to the constant difficulties
which confront the work of the dispensary and medical staffs. Cramped
quarters, long and crowded clinic sessions, inadequate and inconvenient
waiting and dressing-room facilities for patients, constitute working condi-
tions far from ideal.
Taken as a whole, in view of the growing recognition of the commu-
nity worth of dispensary services and the continued increase in the dispen-
sary activities of the city, the physical conditions in the institutions suggest
that (a) a reorganization of clinic schedules is indicated, (b) a rearrange-
ment of space is needed, and (c) additional space is highly desirable.
The limitations under which most of the work is conducted necessi-
tate compromise on the part of the working and medical staffs. The daily
impact of large numbers of patients of all types and ages places a tax
upon dispensary workers even when there is ample space, suitable arrange-
ments, and specially planned facilities. Judging by the experience of other
dispensaries, there is a cost of slow dispensary service to both patients and
workers. Factors related to working environment which are receiving
increasing attention in the business world, appear equally important in
undertakings such as dispensaries, in which the business is to serve human
beings and in which the volume of work indicates a steady increase in
Insufficient information was furnished to permit of any analysis of
dispensary finances. It is not known how much is expended for dispen-
sary care in San Francisco. The accounting systems at most of the larger
hospitals yield such facts, but it appears that the accounts of the smaller
hospitals and of organizations other than hospitals maintaining dispen-
saries as one of their activities, are not so kept as to furnish these data.
It is obvious that the cost of dispensary care should be analyzed with
the same detail as the cost of service in hospitals, i. e., by economic and
medical classification of patients.
The importance of the preventive functions of dispensaries, as well as
their services to the sick, requires more careful record of facts and analysis
104 Hospital and Health Survey
of administrative and medical services than has been undertaken anywhere
in San Francisco.
The opinions of the medical profession in regard to dispensary care
is expressed in the following quotations from letters of physicians reply-
ing to inquiry regarding (a) the need for more dispensary service of any
kind, and (b) the adequacy of the present precautions taken through social
service or otherwise to prevent the abuse by patients of free medical care :
''There is a lack of co-operation between the various departments of the
existing dispensaries. Reports are rarely rendered to the physicians sending
patients to the dispensaries for diagnosis."
'There is need for more efficient collaboration between the medical services
within the clinics in teaching and research, in order that there be more efficient
prevention of disease and treatment of the sick."
"The restriction imposed by the very limited 'free bed' accounts hamper the
care of the sick. The sums available for free care are used to supply medicines,
X-rays, Wassermanns, etc., leaving almost nothing for free bed care."
'We need more support to improve the quality as well as the quantity of
service given. We lack sufficient doctors and are short of nurses and social
"Most semi-private dispensaries are lacking in funds to provide special exam-
inations — such as X-ray- — and lack the needed space for hospital care of dispen-
"Clinic patients, as in other parts of the country, do not receive careful
enough consideration of their condition and complaints — i. e., incomplete histories,
inadequate physical examinations, incomplete laboratory investigation, and ill-
considered treatment. The difficulty lies in the custom of trying to handle all
who come, but also in the training and individual standards of the profession."
"Ambulatory clinic patients frequently require hospital attention and are
unable to get it on account of lack of necessary funds. I refer to such cases as
require but a few days of bed care and to such as do not wish to go, or should
not go, to the San Francisco Hospital."
"It is too easy to secure appointments on our out-patient clinic staffs, and
the work of the men in the clinics is not adequately systematized."
The medical opinion was emphatic regarding the inadequacy of the
precautions taken to prevent dispensary abuse, there being almost unani-
mous opinion to the effect that due precautions are not taken. To quote :
"I believe that at our own clinic fully one-half can afford moderate hospital
and doctor fees."
"I personally feel if the clinics would look up the financial status of more
of their patients, there would be adequate room, and more time and attention
could be paid to deserving poor."
"Many clinic patients can well afford private care."
"Social workers of free clinics seldom investigate financial status of appli-
cants, with exception of Children's Hospital."
"I do not believe that adequate precautions are taken, but it is better to serve
the unworthy than to neglect one worthy."
"Either precautions are not taken or else the free clinics desire such a large
Services for the Sick 105
turn-over of patients (as for student instruction) that all comers are received,
without bothering about their financial status."
"Not enough investigation is made of the income and finances of a patient
applying for free treatment. People who can well afford to pay a private physi-
cian are receiving free medical and surgical care/
The opinions of those connected with the non-medical social agencies
emphasize the need for increased financial support for dispensary depart-
ments. The belief appears to be general that adequate social service, steno-
graphic and clerical staffs are especially needed to provide the most desira-
ble quality of dispensary care.
HOSPITAL SOCIAL SERVICE
Hospital social service in San Francisco is provided by six of the ten
hospitals. Of the two public institutions, one, the University of California
Hospital, has a social service department ; that at the San Francisco Hos-
pital has other functions and is not here included in the social service
resources of the city. Of the privately controlled institutions, five have
established departments — Children's, Lane and Stanford University, Mary's
Help, Mount Zion, and St. Luke's Hospitals.
• Combined, these six departments have a total of twelve workers,
including social workers and nurses, two of them having one worker,
Mary's Help and St. Luke's Hospitals, the majority of the workers being
attached to the departments of the two university hospitals.
As in many other cities, social service has developed largely through
the initiative and stimulus of non-medical and non-hospital groups. In
San Francisco the establishment of the work and its continuation and
growth have been chiefly due to groups of women who, prior to the joint
financing provided by the Community Chest, raised the funds needed and
who continue to supply much volunteer service to the work of many of
The functions of the social service departments in the six hospitals
range from the mere giving of relief and investigating patients' ability to
pay for hospital or medical care, to the most modern type of medical social
In the opinion of both physicians and social workers, there is an
undue amount of time and attention now devoted to the question of finan-
cial investigation, clerical work, and the handling of out-patient depart-
ments, with the result that social assistance which should be available for
attending staffs is much reduced.
A study of the reports of the departments and contact with those in
106 Hospital and Health Survey
the work emphasizes the disproportionate amount of attention which is
directed to work which is not properly medical social work.
As social service is a new element in the hospital family, its position
and functions are not as yet universally recognized, with the result that in
many communities the work is still undeveloped as either an integral' part
of hospital care, or as a general community resource for handling commu-
nity medico-social problems.
The primary function of medical social service— assisting in the medi-
cal treatment of the sick — is largely obscured in San Francisco by the fact
that the work of the social service departments includes the executive con-
trol of dispensary departments, and by the extent to which departmental
attention is focused on financial investigation, determining the ability of
patients to pay, clerical detail, etc.
Social service does not factor in medical care for the purpose of find-
ing out what patients can pay, nor for the sake of helping to run out-
patient departments. Its special work is to furnish information and assist-
ance to physicians for their guidance in the treatment of their patients.
In supplying these it collects, evaluates and interprets facts regarding
environmental, occupational, and family conditions, including the ability to
finance sickness without worry and anxiety.
There is considerable difference of opinion among hospital social ser-
vice workers regarding the extent to which social service departments
should collect financial data, but it is increasingly recognized as part of the
administrative detail properly belonging to admitting offices, and not a
function of a department assisting in medical care.
For an institution wishing to protect its attending staff and contribut-
ing public from imposition by persons who are financially able to meet the
cost of their care, the necessary investigations should be made, but it is
not necessary to use a medical social worker to obtain these facts. The.
work appears to fall to social service because, as hospitals are organized
today, no others within the hospital organization possess the requisite
knowledge regarding standards of living, family budgets, dependency, etc.,
necessary to make just decisions.
The physical quarters provided for the departments in the six hospitals
are generally inadequate and furnish no, or only limited, opportunity for
interviewing patients in privacy, a facility regarded as essential to suc-
cessful social work.
The opinions of physicians and those connected with the non-medical
voluntary agencies reflect the fact that more workers are needed in the
hospital social service field in San Francisco. To quote opinions on the
"We need competent and trained paid social workers who understand family
problems, to follow up patients into their homes and see that the medical treat-
ment they need is carried out."
"I feel that case study is not done well enough. Under the head of medical
Services for the Sick 107
social service, the work is essentially economic decisions rather than medical
social service. "
"There is a need for better organization, less financial investigation and
increased workers. These would permit concentration on medical problems,
"There is excellent co-operation between the medical and non-medical social
agencies, but the limitations imposed on the social service departments make it
almost impossible at times to get patients admitted to the right institution. It is
undeniable that the work of the hospital's social service departments are ham-
pered by the lack of facilities which should be available. I refer to home nursin
service and facilities for convalescents and chronics."
"If the social service workers could devote their time to medical follow-up
and similar social service work, instead of keeping accounts and managing clinics,
we could do better work for a greater number of patients. They do all they can
and are devoted, but their work is organized poorly."
The extent to which social service is used by the various medical ser-
vices of the several hospitals is not shown in the department reports.
There appears to be, however, only small reference of ward cases by
members of the attending staffs. Except for the few services which have
their own social workers, most of the ward patients coming in contact
with social service appear either to have been previously known to the
departments, or to have been discovered through personal visits of workers
to wards — indicating the need for a more clear-cut hospital and medical
staff policy regarding the utilization of social service.
The need for a more active reference of ward patients was clearly
demonstrated during the visits to recently discharged patients. Case after
case presented problems which could have been met if the social service
resources of the hospitals had been utilized, but which only became known
through the accident of the Survey. To cite some of the situations found :
Case No. 19 — One hospital, which has the proper machinery for referring its
ward patients to its dispensary and social service departments, appeared to
have overlooked the question of follow-up and social service supervision in the
case of a mother who had been a free patient in the wards for almost a month
for a rectal operation. The father is a junk dealer and the family poor. There
are rive children, the oldest 15 and the youngest a baby of three months. When
visited three weeks after leaving the hospital, the patient was miserable and was
doing the housework for the entire family. She had received no instruction when
discharged from the hospital, the baby was sickly, but the patient was not well
enough to carry it to the dispensary. The case presented a picture of a sick
mother returning to a home of poverty to take up the burden of caring for a
family of seven — most of them young children. Lacking instruction as to her
further care and unable to adjust home conditions so she could go to the dis-
pensary, she was helpless and despondent. She needed the guidance and friendly
interest of a visitor in her home (preferably one who had seen her in the hos-
pital and had established friendly relationships), if not financial aid to tide her
over the period of her home convalescence.
Case No. 20 — This is a case of a family in which both the man and his wife
were ill. He had been in the hospital for five days with acute tonsillitis and
peritonsilar abscess, his wife having been previously in the hospital for a week
with a throat condition, had returned home the day her husband entered the
institution. When visited his physical condition was poor. He was miserable
and in need of dispensary supervision, but as he worked from 7 in the morning
108 Hospital and Health Survey
to 7 at night, there was no clinic which he could attend in his free time. A
washer in a garage, he was worried about his job, as he had been threatened
with discharge because of his absence from work while sick, although his
employer had decided to give him less money and keep him. This family is
able to meet its ordinary financial responsibilities. The husband makes $4.25 a
day, paid $21 for his wife's stay in the hospital and $15 for his own care.- This
evidently took most of the family savings, for when visited they were having
a very hard time and did not have a cent in the house, although $17 was owing
them. The case was reported to the social service department of the hospital,
which took up the matter with the man's employer, who readily made arrange-
ments for the patient to have all the time necessary to attend the dispensary. It
was evident that all they needed was a little assistance and friendly interest to
right their situation, for they disclaimed any need for financial relief as long as
the husband was working.
Case No. 21 — The patient, a middle-aged woman, had been in the hospital two
days for treatment for cancer, paying $2.50 a day. She had been previously in
the hospital for nineteen days for similar treatment in the preceding month, her
hospital bill at that time amounting to $50. Her condition is so serious that she
will soon be in need of care in an institution for the chronically sick, for she
cannot be cared for at home, as the family consists of her husband, two grown
sons and a child of nine. The father is the sole w T age-earner, making $3.25 a
day. The two sons — one a fireman and the other a machinist — do not work because
"one is nervous and the other has a hernia. " This case presents problems calling
for very special assistance. Provisions will soon have to be made for the patient,
as her condition is progressively serious and she could not receive the treatments
she needs at the hospital of the Relief Home. In addition, a study should be
made of the family with special reference to the claimed disability of the two
sons, and of their responsibility regarding payment for their mother's medical
and hospital care.
Some of the families visited presented health and social problems
requiring close co-operation between medical and non-medical agencies.
That this co-operation does not always exist appears to be due to inade-
quate provision for social service, as reflected in the following cases:
Case No. 22 — The patient was a baby of 21 months, a part-pay patient in the
hospital one day for tonsillectomy. The family, deserted by the father and sup-
ported mainly by State and private funds, consisted of three children, the oldest
under the supervision of the clinic for a misplaced hip due to bone trouble, the
patient, an abnormal baby who, though nearly two years old, did not yet walk,
and a five-months-old baby, apparently well. A feeble-minded uncle comes daily
to assist with the housework, an aunt also occasionally assisting. The patient
had a skin condition that needed immediate medical attention, and was referred to
the hospital's clinic. There had been no follow-up from the hospital, which has
but one social worker.
Case No. 23 — A patient, a man of 31, a lumberman by trade, had been ill a
long time, his present stay in the hospital lasting three months. Both of his
legs had been broken above the knee tw 7 o years previously and he has not been
able to get around since. The bones were not properly set at the time of the
fracture and the patient was in bed thirteen months. His present hospital treat-
ment had consisted of bone grafting. He was receiving excellent care at home,
was being visited by his surgeon or assistant, and was still in a body cast. His
wife was intelligent and everything for his comfort and improvement was being
done. There was, however, a question as to> the favorable outcome of the opera-
tion. This type of case, bedridden for so long a period, is the type for which
occupational therapy has proved highly beneficial. The interest and assistance
of the hospital and of his doctor are evident, the hospital making a charge of
$1 a day and waiving or materially reducing extra charges. The beneficial
results of occupational work as a factor in returning the long-term patient to
Services for the Sick 109
usefulness suggest the advisability of such treatment. The question of the
favorable outcome of the present treatment also suggests the advisability of a
definite occupational program, with reference to possible vocational re-education.
The hospital has no social service department, so close working relationship with
the more specialized social groups is not established.
The three fundamental principles as to organization, function and
policy of social service departments advocated by the National Committee
on Hospital Social Service of the American Hospital Association, in its
report 8 of a survey of social service in Canada and the United States,
1. That the department be organized as a department of the hospital
with its head worker responsible to the superintendent or chief executive
officer of the institution, and that it have its own budget.
2. That there be a social service advisory committee appointed by the
governing board which should meet regularly and which should include
representation of the board and the staff, social workers in the community,
non-professional men and women, the superintendent of the institution and
the head worker of the department.
3. That the department carry on educational work for such groups
as social workers, student nurses, medical students, etc.
As to the first, the head workers of the departments are responsible
to the superintendent, but few of the departments operate on a budget
As to the second, none of the hospitals have advisory committees con-
stituted as outlined, although many of the individual workers feel the need
for closer contact with staffs, outside social organizations and other insti-
tutions, and would welcome such committee guidance. It has been the
experience in other localities that co-ordinating committees organized along
the broad lines suggested anticipate misunderstandings, reduce duplica-
tions and familiarize staffs and boards with community problems as well
as with questions relating to hospital care and service.
As to the third fundamental, the small extent to which the educational
opportunities of the departments are being utilized, suggests that the
developments in this regard do not approximate those in other medical and
nursing educational centers. The effective utilization of some of the
departments is hampered by lack of space and insufficient staffs.
Only a few student nurses and some of the medical students attend-
ing Stanford Medical School have the opportunity to learn at first hand,
tinder trained workers, the relationship between medical and social prob-
lems. Case conferences as conducted for Harvard medical students with
social workers or members of the attending staff of the Massachusetts
General and Children's Hospitals ; visits made by medical students with
workers to the homes of patients, as at the University of Indiana; lectures
to medical students by the head of the social service department, as at
Washington University and the University of Minnesota, are instances
8 Bulletins Nos. 23 and 24, American Hospital Association.
110 Hospital and Health Survey
of the opportunities provided at other universities. The social service
experience of the Stanford students is an excellent beginning, but it is
apparent that of the hundreds of medical and dental students and student
nurses coming within the influence of the two leading universities of the
Pacific Coast, few receive planned experience in a subject so vital to their
Social Service at the San Francisco Hospital
Social service at the San Francisco Hospital is essentially an adminis-
trative matter — the determination of the civil and economic right of
patients to admission to the hospital.
Although there is an increasing effort to co-operate with the private
social and medical agencies, the organization, number of workers and the
functions of the department are not planned for medical social service
In consequence the hospital care is frequently incomplete and pre-
ventable hardships and unnecessary misery are permitted to exist.
The need for an adequate social service department at this hospital,
conceived as an adjunct of medical care, was the striking fact brought to
light through the visits to fifty discharged patients during the convalescent
study. To cite but a few of the cases for which social service was indi-
cated, we can quote the following reports made by the investigators for
the Survey :
Case No. 24 — A young father and mother, with a baby of 18 months and one
ten days old, were found struggling against discouraging odds. The financial con-
ditions were serious, the family living in three very poor rooms and the father
out of work. He had been operated upon in the hospital for mastoiditis and was
still returning for dressings. The mother was endeavoring to do all the house-
work, although recently back from the hospital herself and in need of post-natal
supervision. The family was reported immediately to a relief agency for finan-
cial assistance, the man was referred for suitable employment to the workers
then making a study of handicapped persons, and the mother referred for dis-
pensary care — all services which are commonly handled by a hospital's social
Case No. 25 — A young man in the hospital for a month for an operation for
the removal of a foreign body in the abdomen which had been followed by
abdominal fistula, was in need of special assistance to find suitable employment.
He had had nine operations and much sickness, had become deaf following an
attack of measles, and had had empyema following influenza. A few years ago
he had been operated upon for appendicitis, following which he developed a
hernia, for the correction of which he had undergone two operations, the last
for the removal of some bismuth which had become imbedded in the intestines.
When visited he still had a slight discharge from an abdominal wound and he
was going to the hospital every day for dressings. Although he was improving
steadily in his general health, was most appreciative of all the work which had
been done for him, and eager for employment, he was still weak and was in
need of occupational therapy and of special assistance to find suitable work,
handicapped as he was by deafness and the debilitating effects of prolonged
Case No. 26 — Particularly pathetic was the case of a single man of 68 with
pernicious anemia, who was in the hospital over a month. He was without
Services for the Sick 111
money, drifting from lodging house to lodging house, wandering around office
buildings looking for work. He was referred by the visitor for the Survey to
the workers conducting the study of the handicapped, for possible occupational
placement, or if his condition prevented his working, for admission to the Relief
Case No. 27 — The home environment and facilities for the after care of a
little boy who had a tonsillectomy operation were ill suited to his needs. The
family, in addition to the patient, consists of the father, who is a printer and is
employed all day; the mother, employed from 9 a. m. until 2 p. m., and a child
of 10. The children are left in charge of a cousin of 11 years of age and an
uncle who comes in for lunch. The family takes one quart of milk a day, the
patient getting a cup of milk or cocoa daily. He was in poor physical condition.
His operation, and also dental work at the Dental School, had been arranged for
by the school nurse.
Case No. 28 — A young man was visited who had been unable to work for
nine months because of an inflammatory bone condition of the jaw, following the
extraction of several teeth. Because of his inability to support his family, his
home had been broken up, the patient living with his parents and his wife and
young baby living with her parents. He had been in 'the hospital for two
months, had gained thirty-two pounds, was able to eat only soft foods, and was
going to the hospital daily for dressings. He was in need of special assistance
to find the type of work suited to his condition and was referred to those studying
the problem of the handicapped worker.
Many additional cases presented both major and minor social and
health problems (among them cases No. 9, No. 11, and No. 16, given in
Chapter 2), requiring expert social diagnosis and treatment of matters of
home environment, employment, poverty, hygiene, and a close working
relationship with the attending staff of the hospital and with the various
relief and social agencies of the city.
In view of the fact that there is considerable opinion in San Francisco
to the effect that a central social service agency or the social service
departments of the two university hospitals, could meet the medical social
service needs of the San Francisco Hospital, it should be borne in mind
that the critical time for a patient as an individual being returned to use-
fulness, is prior to or at the time of discharge. It should certainly be the
aim of the city to provide as completely for the indigent sick by means
of all the known supplementary aids to medical care, as private medical
practice provides for the private patient. In the latter the physician gives
the questions of after-care, convalescence, suitability of occupation, etc.,
his personal attention. In hospital ward practice the medical social worker
as his agent acting on his orders, collects and interprets facts related to
similar questions regarding ward patients, upon which subsequent medical
care can be based.
The admirable manner in which the problems of financial investigation
and medical social service work are handled at the Buffalo' General Hos-
pital, 9 a municipal institution, suggests the advisability of a study by the
Board of Health of the methods at this hospital, with a view to applying
somewhat similar principles and methods at the San Francisco Hospital.
9 (a) Bulletin Buffalo City Hospital — Routine Admission of Patients and Financial
Investigation Incident Thereto, 1922.
(b) Report of an investigation of the Department of Hospital and Dispensaries,
Buffalo, New York. Haven Emerson, 1922.
112 Hospitai, and Health Survey
Much can be said in praise of the accomplishments of the individual
hospital social workers, handicapped as they are by insufficient recognition
of medical social service and inadequate provisions for effective work.
It is evident that, in the field of medical social service throughout the
city, there is much to be done. In particular, an increase of workers is
needed so that the departments will be able to do more effective work.
The functions of hospital social service must be more clearly understood,
primarily by hospital boards and executives.
For these purposes there will be required (a) increased funds, and
(b) the establishment of generally accepted standards for the work, spe-
cifically relating* to the following :
Functions of hospitals social service.
Organization of social service departments.
Organization and responsibility of social service committees.
Contact with non-medical agencies.
Use of volunteer workers, etc.
The responsibility for the establishment of standards should prefer-
ably be the particular work of a committee of the proposed Hospital
Council, providing for representation of the social service departments
through their respective head-workers, and of social service committees of
managing boards, the San Francisco Medical Society, non-medical chari-
ties, public health nurse organizations, Department of Public . Health, etc.
VISITING NURSE SERVICE
"The public health nurse is any graduate nurse who serves the health of the
community, with an eye to the social as well as the medical aspects of her func-
tion, by giving bedside care, by teaching and demonstration, by guarding against
the spread of infections, insanitary practice, etc." 10
The nursing service provided by the various organizations of San
Francisco employing public health nurses for visiting in homes may be
classified in four main groups :
(a) Bedside care for general sickness accompanied by health educa-
tion, commonly called visiting nursing.
(b) Bedside care for maternity patients, accompanied by special in-
struction, such as furnished by the Stanford Clinics Auxiliary and San
Francisco Maternity and the University of California Hospital, for mater-
nity patients delivered at home.
10 Nursing- and Nursing- Education in the United States. Report of the Committee
for the Study of Nursing Education, 1923.
Services for the Sick 113
(c) Social follow-up and health instruction of discharged hospital
and of dispensary patients, with occasional bedside care, as supplied by
the nurses constituting the staffs of the Children's and Mount Zion Hospi-
tals Social Service Departments.
(d) Follow-up, education, supervision for special groups, etc., with
no bedside care, as furnished by nurses attached to hospital social service
departments, school, tuberculosis and nutrition nurses, etc., attached to the
Department of Public Health, nurses employed by health or social organi-
zations, such as the Children's Health Center, Junior League, etc., and
those engaged in industrial nursing.
The organizations maintaining the foreg'oing public health nursing
services, together with the extent and character of the service furnished,
(a) Bedside Care for General Sickness Groups —
Metropolitan Life Insurance Company 4
San Francisco Neighborhood Association 3 7
(b) Bedside Care for Maternity Patients —
Stanford Clinic's Auxiliary and San Francisco Maternity 2 2
University of California Hospital Occasional
(c) Social Follow-up, Instruction and Occasional Bedside Care —
Children's Hospital 2
Mount Zion Hospital 2
Schmidt Lithographers . . '. 1 5
(d) Follow-up, Instruction, etc., with No Bedside Care —
Associated Charities 3
Children's Health Center ' . . 1
Junior League 1
Little Children's Aid 1
Mary's Help Hospital 1
Presbyterian Mission 1
St. Luke's Hospital 1
St. Mary's Hospital 1
Stanford Clinic's Auxiliary and San Francisco Maternity 4 14
University of California Hospital 2
Department of Public Health —
Child Welfare 4
Juvenile Court 2
Nutrition Workers 3
School Nurses 21
Social Service Department San Francisco Hospital 3
Social Hygiene 1
Tuberculosis Flome Visitors '." 9 45
114 Hospital and Health Survey
American Can Company 2
Bemis Hag" Company 1
"Bollman Tobacco Company 1
California Candy Factory Y
California Packing Company , 2
Male's Department Store 1
National Carbon Company 1
National Paper Products Company 1
Western Sugar Refinery 1
Western Union Telegraph Company 1 13
From the point of view of financial support, these organizations fall
under one of three groups — those supported by public funds, those deriving
their support from charitable donations and fees of patients, and those
maintained as business enterprises. The following table presents the extent
of the public health nursing service provided by each group :
Financial Support of Public Health Nursing
Number of Nurses Maintained
Type of Nursing By Public By Private By Business
Service Furnished Total Funds Charity Organizations
(a) Nursing Care and Instruc-
tion 7 (8%) . . 3 4
(b) Nursing Care and Instruc- Occasional
tion for Maternity Patients 2 (2%) student 2
(c) Follow-up Home Visits, In-
struction, etc., and Occa-
sional Nursing Care 5 (6%) .. 4 1
(d) Follow-up Home Visits,
Instruction for Special
Groups, with No Nursing
Care 72(84%) 46 13 13
Total 86(100%) 46 (53%) 22(26%) 18(21%)
As shown in the foregoing table, 84 per cent of the nurses visiting in
homes do no bedside nursing, 6 per cent furnish such care only occasion-
ally, 2 per cent nurse maternity patients (exclusive of the occasional stu-
dent nurses at the University of California caring for maternity patients
delivered at home, totaling less than fifty cases yearly), and but 8 per cent
devote practically all their time to bedside care.
It is apparent, then, that what is generally spoken of as visiting nurs-
ing — sometimes called district nursing — is provided in San Francisco by
the three nurses attached to the San Francisco Neighborhood Association
and by the four nurses of the Metropolitan Life Insurance Company.
Public health nursing, as represented in the instructive and special
follow-up nursing services of the Department of Public Health, is well
Services for the Sick 115
developed. The same is true regarding other phases of health education
work provided by the nursing staffs of various private organizations spe-
cializing in health and public welfare activities.
Visiting nurse care of the sick in their homes is obviously so unde-
veloped as to be practically non-existent.
That a city of 540,000 population has available for visiting nurse care
in homes but seven nurses, four of whom are only available for the policy-
holders of an insurance company, indicates a meager development of one
of the outstanding services for modern care of the sick. This is particu-
larly the case, in view of the fact that the visiting nurse is today ranked
as one of the most valuable elements in health work, because of the unique
and intimate place she occupies as the family health educator.
San Francisco's lack of development of this service is unusual. No
other city of its size in the country lacks this service. The number of
public health nurses, and of these the number giving bedside care in the
eight cities of the United States ranging from 400,000 to 600,000 popula-
tion, is as follows :
Number of Public
Population Total Number of Health Nurses
1920 Census Public Health Giving General
Nurses * Bedside Care
Pittsburgh 588,343 112 78
Los Angeles 576,673 64 40
Buffalo 506,775 83 46
San Francisco 506,676 40 3
Milwaukee 457,147 90 26
Washington 437,571 54 26
Newark 414,524 80 13
Cincinnati 401,247 55 16
*Exclusive of industrial nurses and those employed by social service departments.
With so limited a visiting nurse service, it was natural that many of
the cases visited showed a need for nurse follow-up to see that doctors'
orders were being carried out, provide instruction as to diet, hygiene,
health promotion, etc. A few of the patients needing such nursing care
may be cited :
Case No. 29 — The young mother of four children, a colored woman, was a
free patient for six weeks in one of the hospitals, with diabetic gangrene, which
necessitated the amputation of a first finger. When visited she was going to
the dispensary once a week for dressings and was following the diet instruction
given by the doctor at the hospital. The patient returned home to do the work
for her family, the youngest a baby only a few months old. The home was
crowded and untidy, the older children trying to help with the housework. This
patient was in urgent need of the service, supervision and stimulation of a visit-
ing nurse, to instruct and assist her in preparing her diet and to assure the con-
tinuance of her dietary treatment.
Case No. 30 — A patient was in one of the hospitals for five weeks following
an operation for uterine tumor. When in the hospital the incision broke open
eight days after the operation, necessitating a second operation under anesthesia.
As she was considerably nauseated after the second operation, the doctor could
not be certain that the inner stitches held. On discharge the patient was told a
possible hernia might develop in the wound, if at all, within the next few
Hospital and Health Survey
months. No attempt was made by the hospital to keep in touch with her, and
no instruction was given as to the proper course for her to follow during the
period while waiting for the possible hernia to develop.
Case No. 31 — Visiting nurse care would have met many of the needs of a
child of 3 who was sent home after a ten days* stay in the hospital for ,tonsil-
litis, with a bad cough and running nose, no instructions being given 'her mother
regarding any home care. Other children in the hospital had measles, and ten
days after the patient came home she also developed measles. The child had a
persistently poor appetite and a succession of colds, but the mother had had no
instruction regarding upbuilding care or the special supervision needed.
Case No. 32 — A boy of 4 was for four days in one of the hospitals which
has a social service department — diagnosis: tonsillitis and otitis media. The
parents paid 50 cents a day for his care. The visitor for the Survey states:
"If a visiting nurse had been sent to this home for follow-up care the inade-
quacy of this family to follow the instruction given would have been known."
The family was in great need. They had been in California only a few months,
and the father, a shoemaker by trade, had only been able to get work for a
day or two a week since his arrival. There were three children, the oldest 4
and the youngest 1^2 years old. The mother, five months pregnant, did not
know where to go for care. She was referred by the visitor for the Survey to
an agency for financial aid to tide them over their period of trouble and to a
prenatal clinic. Even the $2 charged by the hospital must have been a tax on
a family so handicapped by unemployment and lack of money.
It is judged that a visiting nurse service, in view of the small amount
of dependency in the city, would be at least two-thirds self-supporting.
The experience of other cities in this respect, presented in an authori-
tative report 11 of public health nursing in the United States, is of interest:
Proportion of Patients Paying in Full, in Part or Not At All, for Visits from
Thirteen Privately Supported Visiting Nurse Associations During
the Year Preceding This Study*
Number and Per Cent of ^Per Cent of Patients Paying for Visits-^
Type of Patients Paying in Paying in
Organization Visited Free Total Full Part
5 42.6 57.4 36.3 21.1
6 39.5 60.5 45.2 15.3
7 37.6 62.4 57.3 5.1
8 31.0 69.0 46.9 22.1
9 27.2 72.8 43.9 28.9
10 25.0 75.0 10.0 65.0
11 2.0 98.0 94.4 3.6
12 35.6 64.4 ** **
13 99.4 0.6 0.6
*These figures are based on reports submitted by these organizations. Visits made
for the Metropolitan Life Insurance Company were counted as full pay visits. These
were included in four urban societies' reports.
♦♦Distinction between those paying in full and in part was not made in report given
us by this organization.
li Nursing and Nursing Education in the United States. Report of the Committee
for the Study of Nursing Education, 1923.
Services for the Sick 117
Certain of the cases visited indicate that there is at present a demand
for visiting nurse care among patients who pay in whole or in part for
their hospital care, illustrated in the following:
Case No. 33 — A woman of 41, in the hospital for a month, had an opera-
tion for cancer of the breast so extensive and severe that she had to have a
blood transfusion. Three weeks after discharge from the hospital, when she was
visited, she was sleeping badly, her arm was swollen and painful and her appe-
tite poor. She was attending the hospital's dispensary for dressings and physio-
therapy treatments three times a week. When she came home from the hospital
she was so ill she had been unable to go to the clinic and secured the Metro-
politan nurse who came in once to do her dressing. The picture is one of a
patient returning home sick and miserable and in need of some nursing care.
As she had paid $189.95 for her hospital care, she would have been able to pay
for convalescent care in an institution or visiting nurse service at home had
either of these been available.
Case No. 34 — Another patient expressing a desire for home nursing care, was
a woman who had been in the hospital for a little over two weeks for an opera-
tion for a breast tumor. Although all the nursing care needed was assistance
in taking her bath, getting dressed, combing her hair, etc., as the patient's sister
could do everything else for her, she was employing a nurse for twelve hours
daily. Her needs could have been admirably met by the services of a visiting
nurse for a few hours, The patient expressed the opinion that there was a need
in San Francisco for visiting nurse service for which payment could be made
on the basis of the time used.
Case No. 35 — This case is also of interest as indicating a recognition on the
part of a full-pay patient that the services of a visiting nurse would have met
all his nursing needs after his return home from the hospital. This patient, in
the hospital for five weeks for an operation, was discharged to his private physi-
cian. His dressing was being changed daily, and he wished there was a visiting
nurse service in the city, so he would not have to get up and go to the doctor's
office for dressings.
Case No. 36 — A young woman, in the hospital for fifteen days for an abdomi-
nal operation, received instructions before discharge regarding subsequent care,
but she needed visiting nurse instruction at home to teach her how to carry
them out, a service which was not supplied, although many of this institution's
discharged patients receive instruction at home. This patient is in the part-pay
group, paying at the rate of $4 a day at the hospital, having made arrangement
to pay $15 a month until her bill was paid.
San Francisco needs a visiting nurse association to spread the kind
of service that is being given by the San Francisco Neighborhood Associa-
tion on Telegraph Hill to other parts of the community. Provision should
be made for visiting nurse service so that bedside nursing can be had on
call and at cost by all people who, under medical direction, wish to have it.
The combined opinion of groups concerned with health and sickness
problems of the individual and of the community as a whole, is in agree-
ment that this is an essential service which should be provided. The ques-
tion has received considerable attention, and a representative committee has
collected information and drawn up tentative plans for establishing a visit-
ing nurse association.
It is assumed that such a service will be available for all economic
groups in the population, and that the practice of withholding all visits,
unless there is a doctor in attendance on the case, will be adhered to.
118 Hospital and Health Survey
There is ample experience upon which to draw for guidance in deter-
mining- such details as organization, contact with the medical profession
and hospitals, administration, districting, affiliation with training schools
for nursing, etc.
On general questions, the National Organization for Public Health
Nursing is equipped to furnish counsel and advice of the most valuable
character, while the experience of the San Francisco Neighborhood
Association would afford assistance in adjusting generally accepted
methods to local conditions.
The inadequacies of the present facilities for institutional convalescent
care in San Francisco are well known to all in contact with health
and hospital work. As one social worker said, "The situation is one that
confronts every social and welfare worker in San Francisco."
The Council of Social Agencies, through a sub-committee studying
hospital problems in 1923, reports : "There is a need for a special com-
mittee to investigate the local need for an institution or home for con-
valescent patients from hospitals, especially the San Francisco Hospital,
where convalescent patients could find a temporary home at a minimum
cost while seeking employment instead of being dumped into the cheerless
cheap lodging-house. "
The few facilities for the institutional care of convalescing adults
and children consist of the Bothin Convalescent Home at Manor, Marin
County, 37 beds ; Drexler Hall at Redwood City, 16 beds ; and the Stanford
Convalescent Home at Palo Alto, 16 beds.
The Patient groups received by the three institutions are as follows :
Bothin Convalescent Home — Receives boys and girls between 5 and
10 years of age for general convalescent care and for preventive care ;
and women of all ages — the accommodations for women being limited
to two beds. It receives both pay and free patients and is not equipped
to care for bed cases. Changes now being made will provide ten addi-
tional beds for girls and will make it possible to use all the facilities the
year round instead of only eight months, as formerly, but make no
provision for bed care.
Drexler Hall — Receives girls from 3 to 18 years of age suffering
from orthopedic conditions. The institution is maintained entirely from
private sources and limits its service to free patients. It is not equipped
to care for bed cases.
Stanford Convalescent Home — Receives boys and girls from 2 to 12
years of age, including both pay and free patients, and is equipped to
Services for the Sick 119
care for a few bed cases. An admirably planned unit nearing completion
will provide facilities for 20 bed cases, 10 boys and 10 girls.
In addition to the foregoing, the Ladies' Protective and Relief Asso-
ciation plans to build a home for aged women within the city limits,
which will provide 10 or 12 beds for convalescing women patients, other
than bed cases or mothers with infants or young children.
With these additional accommodations, there will be available within
about one year, a total of approximately 110 beds as follows:
Adults — Men
Children — Boys 10
Girls 10 20
Adults — Men
Women 12 to 14 12 to 14
Children — Boys and Girls 51
Girls only 26 11
Total 109 to 111
The obvious inadequacies of these facilities are apparent, as they
include no provision for adult male patients, none for bed care for women
and only minor provision for up-cases, practically none for mothers with
infants, and but few beds for special patient groups and those only for
The opinions of physicians, hospital administrators, and social, workers
expressed to the Survey, constitute a convincing array of informed opinion
regarding the inadequacies of the facilities.
The members of the San Francisco County Medical Society gave
more attention to the matter than to any of the subjects on which opinion
was asked, 62 per cent of the replies testifying to the need for increased
accommodations. The special groups for which it was considered pro-
vision should be made, according to the number of replies, are :
General Medical and Surgical ; Mental and Neurological ; Obstetrical
and Gynecological ; Pediatric ; Orthopedic ; Ear, Nose, and Throat ; Vene-
real and Genito-Urinary Diseases ; Dental; Eye.
A high percentage of the hospitals expressed opinions which indicate
a pressing need for facilities for free and part-pay convalescing hospital
patients, a few mentioning in particular the need of accommodations for
men, mothers with children, and boys over 10.
Other health agencies emphasized the difficulty experienced in obtain-
ing suitable convalescent care for free and part-pay patients, especially
men, women, boys over 10, and women with cancer, the last reflecting a
rather common confusion of chronic and convalescent problems.
Social service groups co-operating with health agencies were of the
120 Hospital and Heai/th Survey
opinion that there is a general need for facilities for all the economic and
To quote some of the individual opinions :
"The greatest medical need in San Francisco is for free convalescent 'Care."
'The convalescent facilities are limited to adults — children are taken care of."
"Convalescent bed care is almost entirely lacking and available only for an
"Part-pay convalescent care is needed for patients requiring bed care. ,,
"At the present time there are no adequate facilities for convalescent care
for adults in San Francisco. The situation in regard to single men needing care
during convalescence is really distressing. ,,
"Convalescent bed care is very insufficient, especially for children.'*
"Free or part-pay convalescent bed care outside of our large hospitals is
needed for convalescent children."
The unsuitability of such institutions as the Relief Home for con-
valescing patients should need no comment. In the opinion of the super-
intendent of the Home, the morale of the convalescent, particularly the
younger man or woman, is permanently injured by association with the
aged almshouse or chronically ill type of patient.
The problem of meeting the individual needs of convalescing patients
is one touching a wide range of health and social services. It includes
private medical practice, hospital and dispensary service, public health
nursing, medical social service, convalescent institutional care, vacation
camps, rest-homes, etc. Experience has proved that it is only through the
intimate co-operation of these services that the most satisfactory results
The visits to recently discharged patients indicated that satisfactory
convalescence from hospital care is not being obtained in many instances
in San Francisco because (a) co-operation among the various services
concerned is insufficiently developed, and (b) three important services
for supplementing hospital care — medical social service, convalescent
institutional care and visiting nurse care in the homes — are inadequately
Many of the conditions found to exist among the 160 discharged
patients visited in their homes, previously described in various chapters of
this section, reflect in different types of cases the results of the present
inadequate co-operation between certain of the existing services respon-
sible for convalescent care. Additional cases , showing the type of case
for which institutional care was indicated, were as follows :
Case No. 37 — The patient, a single man of about 50 years of age, was in the
hospital for a month with heart disease, and when discharged was unable to
work, without funds, and dependent on friends who were paying his room and
board. He had drifted in to one of the independent dispensaries, instead of the
one to which he was referred, and had been referred also to those working on
the problem of the handicapped. , What the patient needed was care in a well
equipped convalescent home providing medical supervision and facilities for
suitable occupational placement.
Services for the Sick
Case No. 38 — A mother of 21, in the hospital to be delivered of her first baby,
had had a very severe labor necessitating extensive surgical repair. On leav-
ing the doctor told her to take life easy for several weeks, but this was hardly
possible, as her husband had been out of work for some time, had only had
employment for three weeks and was away working in the country. When the
patient was visited, two days after leaving the hospital, she was washing at a
tub placed on a low chair so as to work with less difficulty. The patient paid
$35 for her hospital care, but her financial and physical condition indicated that
she either needed financial relief so that a houseworker could be provided to do
the heavy work and she could take life easy as directed by the doctor, or she
needed care in a convalescent institution until she was strong enough to resume
her normal life.
Case. No. 39 — A mother of 22 with three children, was in the hospital eighteen
days for an operation for chronic appendicitis. On her return home the patient
took care of her two youngest children who required extra watching, and did
all the housework except that which her husband could help her with after he
returned from work, her mother taking charge of the oldest child. It was evident
that this patient would have benefited by a stay in a convalescent institution fol-
lowing her operation and should not have been permitted to return to arduous
household worries and labors. The hospital charge of $15 a week was low,
but high for a family of five supported by one wage-earner making $35 or less
When convalescent care is not adequately provided for, either at home
or in special institutions, waste of hospital service results, due to the fact
that patients are frequently discharged from hospitals before they are able
to take up the burdens of home and occupation. Avoidable suffering, not
infrequently relapses, and often a more or less protracted period of weak-
ness results. With the object of preventing these and similar misfortunes,
patients are retained in hospitals for the acutely sick longer than would
be needed if suitable facilities for convalescence were available. This is
especially true regarding the ward patient, whose home conditions are so
frequently unfitted to the type of convalescence needed.
The extent to which long-term patients are held in the hospitals for
the acutely sick in San Francisco is indicated by the fact that, of the 1805
patients in the hospitals on June 21, 11 per cent had been in the institu-
tions from 31 to 60 days, 4 per cent from 61 to 89 days, and over 9
per cent for 90 days or longer (shown in Chapter 6 of this section),
indicating a total of 442 patients in the hospitals for one month or more.
As many of those hospitalized for three months or longer were obviously
chronic cases, it is assumed that the 15 per cent in the hospitals from
31 to 89 days — 273 patients — represents the convalescing group on this
The experience of the large Eastern cities, where the question of con-
valescent care has received special attention, indicates that institutional
care will be needed for 12 per cent of the total number of hospital patients
cared for yearly. Using the 51,840 patients cared for in the ten hospitals
during 1922 as a basis, it is estimated that, in San Francisco, some 6000
patients annually require institutional care for convalescence.
During 1922, the three existing convalescent homes cared for a total
of 544 patients. As the capacities of two of the homes are being increased
by some thirty beds during the current year, it is estimated that the exist-
122 Hospital and Health Survey
ing facilities can take care of about 1000 of the 6000 cases -needing institu-
tional care annually.
Based upon the commonly used estimate of 17 patients to one bed
per year, 350 beds are required for the 6000 patients.
Long experience in the larger cities of the country indicates that these
accommodations should be apportioned as follows:
Adults — 15 years and upwards — General medical and surgical con-
ditions -. . 120
Children — Boys 6-12 and girls 6-15 — General medical and surgical
conditions, including orthopedic and heart disease •,-..•" 100
Boys — 10 to 15 years 30
Mothers with infants and young children (averaging 60 patients).. 30
Special facilities for cardiacs 40
With but 110 beds available or even planned for, and lacking provi-
sions for many special patient groups, the facilities are entirely inadequate.
In view, however, of the generally high level of living and the relatively
small percentage of dependency, it is possible that San Francisco may not
need to provide as extensively for institutional convalescent care as the
communities on whose experience the estimated number of convalescent
beds needed is based.
It may be found expedient to collect information over a definite
period, in order to verify or correct the estimates herewith presented. The
exact extent to which provision should be made could be determined by
a collective study undertaken uniformly in each hospital, such a study to
include the collection of medical opinion relative to the particular con-
valescent needs of individual patients, namely, whether institutional con-
valescent care, home-nursing care, vacation camp, etc., is needed. These
facts, correlated with facts as to the adequacy of the home conditions for
the type of convalescence required, would furnish the desired information
regarding the particular patient groups for which provision should be
made. Thus one of the groups which will require early and special
attention is the orthopedic child. The opening of the Shriners' Hospital
will probably add considerably to the number of such children needing
long periods of convalescent care. The admirable facilities and achieve-
ments of Drexler Hall suggest the desirability of similar facilities for
boys, and for part-pay patients, both boys and girls.
The convalescent institutions have invaluable first-hand information
regarding the special groups for which provision is needed, and could
assist considerably in any joint program for the solution of the problem.
Their work, conducted with small general recognition of the highly impor-
tant services they render, is founded on the modern idea that convalescent
homes should provide not only medical supervision, but also facilities
for upbuilding and education in health habits.
Services for the Sick 123
HOMES FOR THE INCURABLE AND CHRONICALLY SICK
A comprehensive study of the institutional care of the chronically sick
has been recently made throughout the United States and Canada in
response to a widespread feeling that the problem has not yet received
the recognition it deserves. The report 12 briefly states the problem:
"A chronic patient may be described as one who requires hospital care for
a period of from three months to several years. From the point of view of
institutional care, these patients may be grouped into three categories — Class A,
those requiring medical study for diagnosis and treatment; Class B, those requir-
ing nursing care only;. Class C, those requiring custodial care only."
The report stresses the complexity of the problem of caring for these
various groups and the different types of institutional care demanded, and
is clear-cut in stating standards regarding the facilities which should be
available for the three groups :
'The proper care of a Class A patient demands a complete hospital organi-
zation with a resident staff, an attending staff on which all of the specialties are
represented, complete laboratory, X-ray and operating-room equipment, skilled
nursing and dietetic management. Class B patients require much less specialized
attention, but should command an excellent nursing service, controlled by a con-
scientious medical staff. Class C patients need the least care. As the classifica-
tion implies, the treatment of this last group is largely, custodial in character.
These patients are retained in an institution; not because they require hospital
care, but because poverty makes home care impossible. The problem is economic,
not medical. All of their wants are supplied with due regard to their respective
disabilities by proper sleeping and living accommodations and food."
San Francisco has two institutions planned and equipped for the care
of the chronically sick, namely:
(a) Hospital of the Relief Home for the Aged and Infirm, conducted
for indigents by the Board "of Health.
(b)" San Francisco Home for Incurables, a privately controlled insti-
The accommodations and facilities available in these two institutions
may be briefly stated:
(a) Hospital of the Relief Home for the Aged and Infirnv—The Hos-
pital of the Relief Home, with a capacity of 500 beds, accommodates a
number of widely different groups, as follows :
Arrested Tuberculosis (aged chronic) 1 25
Cancer '.-. .-. 25 '20
Paralytic 60 25
Aged Chronic '.'.'. , 160 45
Custodial 100 40
Totals 370 130 500
12 Dr. Ernest P. Boas. Director of the Montefiore Hospital for Chronic Diseases, New
York, and Dr. A. K. Haywood, Superintendent Montreal General Hospital, Montreal,
Canada. Modern Hospital, July, 1923.
124 Hospital and Health Survey
As the hospital is also the infirmary of the Relief Home, there is a
constant interchange of inmates back and forth between the Hospital and
the Home units.
The physical condition of the 1244 inmates in the Home and Hospital
sections on July 21, 1923, indicates to some extent the complexity of the
hospital and custodial problems existing in this type of public institution:
Men Women Total
Epileptic 16 6 22
Blind 29 6 35
Deaf 28 12 40
Mentally Incompetent 71 58 129
Crippled ...116 31 147
Bedridden ! 120 43 163
Able to Work 297 31 328
Old and Infirm 283 97 380
Totals 960 284 1244
Due to the fact that the Hospital and Home statistics are not sepa-
rately assembled, facts as to the number of these which were hospital
patients, were not available. It was stated, however, when the institution
was visited, that the patients in the Hospital numbered approximately 300,
many of the deaf, blind, and crippled not in need of hospital care living
at the Home.
The medical service available for the 300 patients consists of two phy-
sicians who attend every morning and are on call at all other times, one
of them living on the grounds ; specialists being available for consultation
when needed. There are no resident physicians or interns. The six medi-
cal students who work in the Hospital at night do not serve in an intern
capacity, but as orderlies.
The Hospital has no laboratory, all laboratory specimens requiring
examination being sent to the San Francisco Hospital. Patients requiring
X-ray examinations are sent either to University of California Hospital,
but four minutes from the institution, or to the San Francisco Hospital.
The nursing of bed patients is performed by aged inmates of the
Home, working under the direction of nine trained nurses.
The planning, preparation and service of food is not under the super-
vision of a trained dietitian.
There is no social service department.
As no separate records are kept for the Hospital section, there was
no information assembled which would indicate the number of sick receiv-
ing hospital care, the medical conditions cared for, results, etc.
Services for the Sick
The statistics for the fiscal year ended June 30, 1923, which reflect
to some degree the sickness problems involved, were as follows :
Admissions — 1922
Through Board of Health 613
From San Francisco Hospital 259
By Superintendent (readmissions) 31
Discharges — 1922
At own request 403
Died . 249
Left without permission 105
Overstayed pass 55
Sent to San Francisco Hospital 48
Sent to State Hospital 13
Sent to Tuberculosis Hospital 7
Ages of Inmates — 1922
20 to 30 9
30 to 40 26
40 to 50 51
50 to 60 143
60 to 70 300
70 to 80 312
80 to 90 109
90 to 100 10
Average age of inmates, 66.88 years.
30 to 40 . . 3
40 to 50 .10
50 to 60 34
60 to 70 75
70 to 80 92
80 to 90 34
90 to 100 1
126 Hospital and Heai/th Survey
The financial report of the institution shows a. total per capita mainte-
nance cost for inmates of $.706 a day, made up of the following cost units:
Unit Costs— 1922
Fuel ; ... . .037
Drugs, Medical and Surgical Supplies...... ., .014
Miscellaneous Items, new equipment, repairs, etc .143
Total . .... $.478
Payroll, employes 179
Payroll, inmates 049
Total i $.706
Compared with standards of care quoted earlier in this chapter, the
facilities maintained by the city for its indigent infirm and chronically sick
suggest the need primarily for increased expenditure of funds to provide
better hospital standards. With no separate costs available for the hos-
pital, the per capita amount expended for the care of the sick is not known,
but the observations of the Survey and the opinions of local social workers
familiar with the conditions, force the conclusion that the city has not been
liberal in the amounts allowed for hospital maintenance and medical and
nursing care at the Relief Home. It was understood that the immediate
expansion definitely planned for at the institution does not include changes
in the hospital, but that a program for increased facilities for the sick at
some future date not yet determined has been arranged.
(b) The San Francisco Home for Incurables — The San Francisco
Home for Incurables admits full pay, part pay and, in some instances, free
chronically sick patients, including both bedridden and ambulatory cases.
Patients requiring hospital care are not received, as the institution is not
equipped to care for them.
The Home has a capacity of thirty-nine, as follows:
In wards for women 4
In wards for men 5
In double rooms , 10
In single rooms 20 39
The conditions received are mainly paralysis, senility, arthritis, etc.
Patients with disturbed mental conditions, drug addicts, and alcoholics are
The turnover of cases is low, as there were only 34 admissions, during
1922. There were 29 discharges, 16 of them deaths.
The institution has a high percentage of use, and is adding a new
wing providing eight rooms for the use of women with incurable or non-
Services for the Sick
operative cases of carcinoma, and similar accommodations for men are to
be constructed in the near future. The experience of the Home indicates
there is at all times a demand for beds, on an average of three cases a
week being refused because of lack of room. It is the opinion of those
connected with the Home that at least forty more beds could be used, if
The institution is maintained at a per capita cost of $2.40 a day, but
the financial data furnished were not sufficiently complete to permit of
The arrangement and equipment of the building and the directing
policies reflect excellent management. It is believed that the publication
of an annual report of the institution's activities would awaken further
interest in the problem of the care of the chronically sick.
The opinions expressed by many physicians, nine hospital executives,
and over two-thirds of the health and social workers replying to direct
inquiry on the subject, appear practically unanimous regarding the inade-
quacy of the facilities afforded by these two institutions. A few of these
opinions, herewith presented, indicate that the subject offers definite prob-
lems, as follows :
"The care of the aged and infirm is a decided problem, due to the inade-
quacies of our institutions and the lack of visiting nurse care in the homes."
"The Home for Incurables provides a very excellent service for those who
can pay a moderate amount. Reduced rates are given to certain patients, but the
accommodations of the home are very limited. The service for chronic patients
at the San Francisco Relief Home does not meet the standard of the patients
nor their friends. The city has not provided the money necessary to maintain
hospital service, and patients transferred from the San Francisco Hospital to
the Relief Home feel very bitterly the change of standards. There is the greatest
need for the development at the Relief Home of a hospital for chronic cases
with hospital standards, with a medical staff, adequate nursing facilities and diet
that is appetizing and tempting to those who are chronically sick. It is believed
that the Supervisors and people of San Francisco would willingly pay the cost
of such a standard if those who are directing the social work of the city make
an organized demand for it. It has, however, been fallaciously assumed that
money for this purpose would be provided at the expense of money needed for
curable patients who were acutely ill. There is, however, no question that the
need of the curable patients should have precedence, but in a community as
wealthy as San Francisco there is no reason why both should not be provided
for. There is a special need for the development of proper care for incurable
cancer patients. From our experience, I believe a study of the situation would
show that the majority of hopeless cancer patients discharged from San Fran-
cisco Hospital referred to the Relief Home, refused to go there and either return
to rooms in lodging houses or to their own homes, where they cannot receive
the care they need, especially in the later stages of disease."
"In regard to facilities for chronically ill who could afford to pay, I believe
that there is need for additional facilities at a moderate price. What is really
needed is a semi-charitable home where people of small means can care for their
chronically ill, at, say, not over $50 a month. There is nothing in San Francisco
today that meets this problem."
"Institutional care for chronic patients is inadequate for free and part-pay
patients, particularly for cancer cases."
128 Hospital, and Health Survey
"Institutional care for chronic patients is practically lacking for those who
'The placing of the totally blind who are without funds and cannot follow
their former vocation owing to their physical debility is most difficult."
The result of insufficient or inadequate facilities for the chronically
sick is commonly shown in the extent to which beds in general hospitals
arc used for long-term patients — that is, patients remaining for three
months or more.
The census of June 21 showed an extensive use of the hospitals
for long term patients. Of the 1805 cases, some had been hospitalized
from five to ten years and over, and many for more than a year. As
shown in the accompanying table, 169 patients — 9 per cent of the total
number — had been in the hospitals three months or longer:
Long Term Patients in General Hospitals* — June 21, 1923
Time in Patients
Hospitals No. Pet.
10 to 15 yrs 2 1
5 to 10 yrs 2 1
1 to 5 yrs 41 24
S mos. to 1 yr.. 17 10
4 to 8 mos 66 40
3 to 4 mos 41 24
of Payment —
P. Pay Free
169 100 122 47 104 65 61 29 79
(72%) (28%) (61%) (39%) (36%) (17%) (47%)
See lists of long-term patients, Section V, page 150.
It is evident that on this one day the patients hospitalized from
four to eight months constituted well over a third of the long term cases,
those from one to five years and from three to four months constituting
each about one quarter. The high percentage of adults reflects the
scarcity of facilities for the adult chronic patient; and the percentages
of full pay, part pay and free cases, the economic groups for which
institutional care is sought. As the per capita cost of care in a hospital
for the acutely sick is more than double that of an institution for chronics,
it is apparent that the free care furnished the 108 part-pay and free
patients is an expensive form of charity.
It is not presumed that all the 169 patients are chronically sick, as
the mere fact that patients are hospitalized for a three months' period or
longer does not necessarily mean that they are not properly hospital cases.
But even a brief study of the diagnoses of these patients suggests the prob-
ability that at least 90 per cent do not belong in general hospitals main-
tained for the acutely sick.
The problem of the chronically sick could properly be made a subject
of special study by a committee of the proposed Hospital Council. The
facts made available through the national study previously mentioned
Services for the Sick 129
would furnish valuable aid in formulating standards and developing a
The sympathy and understanding with which so many free patients
have been maintained without charge or at exceedingly low rates for so
many years, justifies the opinion that the individual hospitals have a con-
siderable knowledge of the patient groups for which provision should
be made, invaluable in the study of the problem.
Increased social service facilities for all hospitals, and particularly
at the San Francisco Hospital, would be of material assistance in dealing
with the type of problem presented in the chronic patient. The estab-
lishment of a visiting nurse service would make it possible to care for
a certain number of chronic patients in their homes. This has been the
experience of many other localities. For example, the Victorian Order of
Nurses in Montreal maintains two visiting nurses, especially selected
because of their personal interest and fitness, who care only for cancer
patients in their homes.
Although the number of long-term patients in the hospitals furnish
some index of the chronically sick for whom special institutional provision
should be made, any well considered plan for this patient group would
naturally include consideration of the service which would be available
(a) Increased social service.
(b) The establishment of a visiting nurse service.
(c) Increased facilities for hospital care at the Hospital of the
While it is recognized that the elementary reason for the association
of the privately supported agencies operating for the prevention and relief
of dependency and disease, as members of the Community Chest, was to
reduce duplication of appeals for funds and to secure adequate pro-
portionate support for all such community services as seemed to be indis-
pensable, the organization of functional committees and the undertaking
of this survey express a determination on the part of the officers of the
Chest to direct inquiry into the social causes and results of preventable
sickness, as well as to relieve manifest distress, to crystallize public opinion
in the field of health promotion, and to prepare plans for better services
capable of using all the resources of the community for the care of sickness
and the protection of health.
'The holding of public confidence through educational work all the year
round, is the rock upon which the success of a federation must.be built. Success
or failure in raising the combined budget is not a cause, but an effect of public
"How can the Community Chest vitalize community social work by securing
active, continuing personal participation in the work of individual agencies? Fed-
erated financing, by freeing the agency executive of the burden of money raising,
gives him an unexampled opportunity for enlisting the interest of thoughtful people
in the work of his particular agency, without regard to the size of their monetary
contribution." (Survey — June 15, 1923.)
While it is obvious that there should be justification for the expense
of a survey in the specific recommendations dealing with appropriations
requested by individual institutions, it has been understood that policies,
plans and programs affecting existing public tax-supported agencies, or
dealing with proposed new private agencies should be considered whether
or not they afifect the financial obligations of the Chest.
The scheme of organization of the Community Chest of San Fran-
cisco is such that while proper control of finances is vested in a group
chiefly experienced in business and commerce, excellent protection of the
interests of the professional groups responsible for the technical services
to the community is provided through representation from the important
committees such as that on Hospitals and Health Agencies.
It is believed to be the wise policy, for the present at least, for the
Community Chest to use its position to sponsor or disapprove of fund
raising for endowment or building purposes, but not to participate in efforts
to add to the capital account of any of the agencies or institutions for the
current expenses of which it now makes appropriations.
If the Community Chest makes an appropriation to a hospital or dis-
pensary on the basis of the amount of service to the sick for which the
hospital is not paid by patients, it is obvious that such a hospital must
agree to accept patients for care even when these are not able to pay,
as long as there are services available appropriate to the needs of the
Of the twenty cities* of over 100,000 population in the United States
and Canada where federated fund raising and central control of distribu-
tion of voluntary contributions were in effect as of June, 1-923, appropria-
tions were made to some or all of the privately supported hospitals of
the community in all but three instances (Denver, Minneapolis and Port-
land, Oregon), although the sums allotted to hospitals in many instances
were often only to meet the expense of social service work for the patients.
In a bulletin (No. 12) upon the Non-Financial Activities of Federa-
tions and Chests, issued in June, 1923, by the National Information Bureau,
a great majority of the sixty-six communities reported upon included
in the functions of the Chest or Federation very important non-financial
Among the benefits which Community Chests have brought to a
number of cities are: study of the community as a whole to permit of a
reasoned diagnosis of social, economic and health problems ; central col-
lection of facts as to the service of all similar agencies; standardization of
practice in reporting upon the operation of hospitals, based upon uniform
To accomplish these results in San Francisco it will be found neces-
sary to establish a Hospital Council upon which there will be represented
the managing board and the administration of each hospital whether or
not the hospital receives funds from the Chest. A central purchasing
bureau would probably be the first activity of such a council.
It will probably be found as progress is made in the co-ordination of
agencies dealing primarily with health, as distinct from sickness problems,
and in the formation of a hospital council, that the Committee on Hospitals
and Health Agencies of the Council of Social Agencies will be concerned
almost wholly with the health work and will need some one trained in
collecting and interpreting the facts upon which policies in health ad-
ministration and education are based, to act as a permanent secretary.
♦Cincinnati, Grand Rapids, Montreal, Canada; Portland, Oregon; St. Louis, The
Oranges, N. J.; San Francisco, Toledo, Ontario; Minneapolis, Philadelphia, Cleveland,
Kansas^City, Oakland, Rochester, St. Paul, Dayton, Milwaukee, Detroit, Seattle, Denver.
132 Hospital and Health Survey
DEALING WITH THE APPROPRIATION OF FUNDS BY THE COM-
MUNITY CHEST TO THE PRIVATELY SUPPORTED
HOSPITALS AND HEALTH AGENCIES
It is understood that appropriations for capital account are not con-
sidered to come within the scope of the Community Chest at present.
Therefore, under this section of the recommendations only such items
will be considered as are properly included under current expenses, or
maintenance and operation.
Before offering suggestions as to appropriation by the Community
Chest to hospitals which are now receiving or have applied for funds,
the principles upon which allowances from a common purse should be
made to agencies giving care to the sick should be agreed upon.
Inasmuch as the interest of the contributor to a community chest is
theoretically not in institutions but in services to his fellow citizens who
may be sick or indigent, we should measure the right of a hospital, dis-
pensary or other agency for care of the sick or protection of health to
participate in the fund collected, by the quantity and quality of services
which the particular institution or agency can show from its books have
been rendered, which have not been paid for by the patients or through
other earnings, or endowments.
Two other bases are now in general use to determine the amounts
to be appropriated to hospitals, that of the deficit in annual operations,
and that of the sum of voluntary contributions from the public in recent
years, the use of either of which may be justified as a temporary expedient
pending the collection of comparable facts as to the amount, quality and
cost of service given, but neither of which should be adopted as a con-
tinuing policy by a community chest or welfare federation.
It will presumably always be a matter of pride and rivalry anion
hospitals not only to give as high a quality of medical service as the
patient needs but to provide this at as low a cost as good administration
Since no fair basis of measurement of quantity, quality or cost of
hospital or dispensary care can be arrived at among the hospitals of
San Francisco until modern accounting methods and departmental records
of service and unit costs are adopted, approximately on a uniform basis
by all the medical service institutions, and until the services are so reported
that the number of days of hospital care, or the number of visits of
patients to dispensaries can be classified according to the main medical
groups, such as medical, surgical, obstetrical and children, and according
to their financial relation to the hospital, i. e., free, part-pay or full-pay
patients, and the cost of services can be reported upon by substantially
these same groups where practicable, no institution can make its right to
a particular sum from the Community Chest clear to the Trustees of the
It is to be clearly understood that in calculating the cost of hospital
and dispensary care there should be included the expense of laboratory
diagnostic procedures and special therapeutic treatments, as disclosed by
an accounting for the operation of these services, not as based upon
arbitrary schedules of prices charged, comparable to those of commercial
organizations operating for profit.
It is obvious that there will be considerable variation in the cost of
essentially similar services given at different hospitals, according to the
comfort, space, character of personnel, housekeeping standards, etc., and
it may prove necessary for the Chest to establish a maximum per capita
cost of care for bed and dispensary patients, beyond which the cost of
treatment of the sick will not be met, except where there is some par-
ticular or special treatment unobtainable elsewhere, and essential to the life
and health of individual patients.
It is recommended that :
1. Basis for 1924 Appropriations — Appropriations for 1924 to hospi-
tals and dispensaries be continued on the same basis as in 1923, although
this is recognized as an unsuitable permanent or continuing financial policy.
The principle upon which appropriations should be made, namely, for such
amounts as can be shown by a hospital or dispensary to have been spent
for the care of the sick which patients have not met in whole or in part
by their own payments for care, cannot be adopted until next year,
because it will not be possible in a shorter period to institute in the
hospitals and dispensaries such a system of cost accounting and book-
keeping as will permit monthly reports to the Community Chest of the
services rendered to free, part-pay and full-pay patients, and their cost.
As soon as practicable after such a system is put into operation in
any hospital or dispensary the Community Chest should use the monthly
reports of hospital operation and the costs of free services as the basis
of annual allotment of funds to these institutions, having in mind at the
same time the importance of providing for improvement in quality and
completeness of service as well as the propriety of meeting the cost to
which an institution has been put in caring for the sick of the community
who could not pay all or any of the expenses of their treatment.
2. Franklin and University of California Hospitals — That special
reconsideration be given to the matter of appropriations to the Franklin
Hospital and to the Women's Auxiliary of the Out-Patient Department
of the University of California Hospital:
(a) Franklin Hospital — In the case of the Franklin Hospital (which
received an appropriation of $15,000 in 1923), a subsidiary of the German
General Benevolent Society, organized for sickness insurance and other
purposes on a commercial basis, the hospital appears to have closed its
year's operations in 1922 with a profit of $545, which was applied to a
reduction of the $34,195 deficit shown on the books of the benevolent
134 Hospital, and Health Survey
association. Furthermore there appear to be carried on the pay roll of the
hospital the salaries of four physicians whose functions are solely to serve
the members of the Benevolent Society. In estimating the cost of free
service provided by this hospital to the sick of the community these salaries
should not be included.
(b) University of California Hospital — As to the Women's Auxiliary
of the (Hit- Patient Department of the University of California Hospital it
is suggested that it is an unwise policy for the Community Chest to make
any appropriation for services to the sick which are supplied by a hospital
supported by city or state taxes. Social service differs in no essential
from various other hospital or dispensary services of a professional nature.
The fact that the Regents of the University have not seen fit to provide
for all the medical social service which is found necessary at this hospital,
while they have supplied funds adequate for dietetic, anesthetic, nursing
and other services of a professional character, is a matter of much public
interest, but it is not conceived to be the duty or proper function of private
agencies, using funds collected through voluntary contributions, to select
one particular essential function of a state tax-supported hospital and re-
lieve the tax levy of this burden.
Such part of the funds which have been spent by the Women's
Auxiliary of this hospital, as have been used for material relief of the
indigent sick, should be provided through existing general relief agencies in
It is quite possible that the Community Chest may feel that the
medical social service provided in the interest of the patients of the
University of California Hospital is too important to allow it to lapse
until the State provides for it. If so, is it not obviously the duty of the
Chest to provide for similar service at the San Francisco Hospital, where
the city has not yet installed it?
With regard to appropriations requested by the University of Cali-
fornia Hospital to meet the cost of care of free or part-pay patients,
resident in San Francisco, it is considered that subsidizing a tax-supported
public hospital through charitable funds would be a fundamentally wrong
principle to establish.
3. Lane and Stanford University Hospital — With regard to the
requests of the Stanford Clinics Auxiliary and the San Francisco Ma-
ternity, and the Lane and Stanford University Hospital it is recommended
that these be granted in 1924 as in 1923, but it is suggested that in the
future no separate appropriations for hospital or dispensary services for
free and part pay patients be considered. All hospital departments should
be under the direct administrative supervision and control of the super-
intendent through whom all requests for funds should go to the managing
board of the hospital, the latter to approve appeals for appropriation from
the Community Chest. The facts that Lane and Stanford University
Hospital received no money from city or State taxes, that it is the hospital
of an important teaching institution, and that, coupled with high-grade pro-
fessional and nursing services, there has been provided a medical social
service department of excellent quality, all seem to justify particularly
favorable consideration of the request for such funds as will permit this
hospital to offer more beds for the care of free and part-pay patients.
4. Osteopathic Clinic — It is recommended that no appropriation be
made to the Osteopathic Clinic for the reason that the services for the
sick are of a quality too low for the Chest to sponsor. It is doubtful if
anything* approximating adequate or responsible diagnosis and treatment
of disease, as these are understood and practiced in the other medical
institutions assisted by the Chest, is to be had at the Osteopathic Clinic.
5. French Hospital — It is recommended that no funds be granted
to the French Hospital of the Societe Francaise de Bienfaisance Mutuelle.
It appears from the report of the Society that in 1922 of the 46,766 days of
hospital care provided, but 103 days of care were given to patients who
paid no part of the cost of their hospital services.
It appears that in 1922 the fees of beneficiaries of the Society, a sick-
ness insurance association, organized on a commercial basis, which operates
the Hospital, together with fees of other pay patients, met all operating
expenses and left a balance of profit for the year of $14,092.
6. Mary's Help and St. Marys Hospitals — A situation exists in
Mary's Help and St. Mary's Hospitals peculiar to hospitals managed by
Catholic Sisterhoods where many of the professional, nursing, administra-
tive and office positions are filled by Sisters, for whose salaries no sum is
set aside in the hospital budget equivalent to the amount which would have
to be paid at prevailing rates for these services.
The Community Chest would be justified in making appropriations for
the present to these two Catholic hospitals on the same basis as in the
case of other privately supported hospitals, but several situations brought
about in the financial status of the Sisters' hospitals by the gift of their
services require consideration before establishing a definite policy for the
It appears that at St. Mary's Hospital, in 1922, income exceeded ex-
penditures to the extent of $31,207, which is $7807 more than the hospital
would have had to pay for Sister services if the usual rates for equivalent
positions had been paid here as in the case of other hospitals in San
Francisco. The profit shown on the books for 1922 — $31,207 — was added
to the capital account of the hospital, and any appropriation of the
Community Chest to this institution under these conditions would to all
intents and purposes constitute a contribution to the hospital's building
fund, an objective alien to the purposes of the Community Chest at present.
Similar facts cannot be presented for Mary's Help Hospital, as this
institution did not furnish a complete financial statement. However, it is
estimated that the Sisters' services for hospital purposes represent a sum
of $14,700 a year, at present rates for equivalent positions.
When the cost of hospital or dispensary care of free and part-pay
patients at either of these two hospitals is presented, as suggested in the
136 Hospital, and Heai/th Survey
introductory remarks of this section, there should be shown as a book-
keeping item of hospital expense a sum equivalent to the estimated value
of such Sisters' services as are devoted to hospital work, and the per
capita cost oi care per day or the cost of a dispensary visit should be
based on a total of expenses which includes this item.
7. Proposed Hospital Council — It is recommended that for 1924 the
Community Chest provide the funds necessary to meet the cost of a Hos-
pital Council, the functions of which would be ultimately as suggested in
Section III, but for the present should consist, so far as paid services are
concerned, of a central record office and purchasing bureau supplied with a
modest revolving fund to permit of the taking advantage of cash discounts,
etc. It is believed that an initial annual expenditure of not over $15,000
would show savings to a considerably greater amount in hospital expendi-
tures and at the same time provide the opportunity and occasion for a
continued and current study of all hospital problems.
8. Secretary to Proposed Health Council — It js recommended that
the position of Secretary of the proposed Health Council be created in
the offices of the Community Chest or Council of Social Agencies, such
a position to be held preferably by a physician qualified in public health
work, possibly on part time, the functions of this office to be as described
in Section II, but at least to include those of executive officer of the
proposed Health Council under which he would initiate and share in
carrying through more detailed studies of the health services of San
Francisco than w T as found possible during the Survey herewith reported.
9. Assistant to Division of Child Hygiene of the Department of Public
Health — It is recommended that until the city provides the funds, the
Community Chest appropriate up to $5000 towards the salary of a full-
time physician to assist the Health Officer in developing a complete pro-
gram of Child Hygiene as outlined in Section II.
It is not considered a proper policy for a city employe to be paid by
a private organization, nor that a private agency should decide upon and
pay salaries to those in public office or serving public functions, which
are out of proportion to the salaries paid on the city budget. However, it
ought to be possible to make available to the Health Officer and for public
service in that field an assistant whose salary the city would soon meet ;
such a person, for instance, to supplement rather than replace the present
part-time physician, head of the Bureau of Child Hygiene of the Health
Department, and to be responsible to him. A precedent for such private
subsidizing of city health personnel has occurred in the field of tuberculosis
work, where salaries of Department of Public Health nurses were for a
time met by the San Francisco Tuberculosis Association and from private
10. Hospitals Establishing Social Service Departments — It is recom-
mended that the Community Chest encourage each of the hospitals and
independent dispensaries to which it may allot funds for general maintenance
and support, to establish medical social service under its own independent
direction, and that, to secure the early establishment of such an essential
professional service in connection with the medical and nursing services
as they are now usually organized, the Community Chest offer to meet
the expense of at least one trained medical social worker in each of
the assisted institutions.
It may be found impracticable for the San Francisco Hospital to add
an adequate medical social service to its existing hospital facilities, as
promptly as is recognized to be desirable by the Board of Health, the
Health Officer and the Superintendent of the Hospital. Until such time
as this service, of particular value to the sick poor of the city, for 92
per cent of whom the San Francisco Hospital provides bed care, is estab-
lished and maintained out of the tax levy, it is probable that through joint
action of the relief agencies much could be done to remedy the incomplete-
ness of hospital care, as revealed in the study of recently discharged
patients. For such additional social service if provided by competent
medical social workers, the Community Chest might be asked to con-
tribute further to the social and relief agencies.
11. Establishment of District or Visiting Nurse Association — It is
recommended that a sufficient sum be set aside in 1924 to meet the expense
of organizing and establishing a District or Visiting Nurse Association
under the auspices of the Community Chest or of the Council of Social
and Health Agencies.
Educational services and health protective as well as sickness and
maternity bedside care in the homes, under the direction of the private
physicians or of physicians of hospitals and dispensaries, are nowadays
recognized as so fundamental a part of a sickness and health service in
any community that the establishment of such is strongly urged. In a city
such as San Francisco, where there are only 1200 families among the
whole population found to require material relief, it is altogether likely
that a visiting nurse service for free, part-pay and full-pay patients in
their homes, such as is contemplated, would soon become at least 60 per
cent self-supporting. It is of primary importance that the directing body
or managing board of such an organization be formed of men and women,
among whom there should be representative physicians, nurses and men and
women with a knowledge of social and relief work, but the actual admin-
istration of the services should be left to a Director of Nurses, equipped
by training and experience in public, health nursing, and wholly untram-
meled in the sphere of her professional work.
It is particularly fortunate that just at this time there has been
completed the first nation-wide study of the organization, costs, and services
of visiting nurse associations by a committee of the National Organization
for Public Health Nursing. The report of this Committee's work will be
available in preliminary form within a month for the use of the Com-
munity Chest and it is recommended that action in the matter of organiz-
ing a Visiting Nurse Association await careful consideration of this text.
12. Convalescent Homes and Homes for Chronic Invalids — It is
recommended that the Community Chest authorize and use its influence to
endorse and encourage the raising- of funds for the erection of Convalescent
138 Hospital and Health Survey
I Ionics and Homes for Chronic Invalids where those able to pay all or
part of the cost of their care should be provided for, when they are no
longer in need of the services and equipment of a hospital primarily
designed for the care of acute and relatively brief periods of illness. This
is a matter which concerns intimately the problems of hospital operation,
for at present an excessive expense is being met by the hospitals for the
care of many convalescent and chronic invalids who could be as well or
better provided for at half the daily cost per capita in Homes constructed
and operated to meet their particular needs. The need of materially in-
creasing the hospital facilities of San Francisco can be postponed for many
a cars if adequate provision is made for chronic and convalescent patients
who now use hospital beds to the disadvantage of themselves and to the
excessive expense of the hospitals.
In addition to the provisions planned for or under construction under
the auspices of the Board of Health at the Relief Home there are now
needed for the patients improperly provided for in the hospitals of San
Francisco 100 beds for chronic invalids. There are 265 beds needed for
convalescent patients. To meet these needs there are at present only
thirty-nine beds for chronic invalids, and eight more under construction
for cancer patients, and sixty-nine beds for convalescents, with thirty more
DEALING WITH PROGRAMS IN THE FIELD OF PUBLIC HEALTH
FOR THE PROMOTION OF WHICH THE COMMUNITY CHEST
MAY BE EXPECTED TO LEND ITS DIRECTING
1. Health Education— -First in order of importance in the field of
health promotion, sickness prevention, and the postponement of death is
education of the public in the principles of right living and in the means
The two logical and appropriate agencies for carrying on education
in health are the schools and the Board of Health. There is needed a
policy, a plan and the practice of education of children in each grade,
according to their capacities, in the simple biological truths upon which
health, its establishment and maintenance depend.
It is not additional teachers or new or more equipment that is needed
in the schools but such rearrangement of subjects, with such alteration
of emphasis, example and proportion in the school curriculum as will per-
mit the teaching of the facts of life in every department. Teaching of
hygiene, or physical training or kindred subjects as additions to a crow r ded
curriculum will never accomplish our purpose, which is to have health,
and knowledge of it permeate the teaching of every topic of the school
course, and the daily practice of teachers and children.
A Board of Health which is allowed no appropriation by the city to
permit the Health Officer to carry out any educational activities except
through the occasional opportunity of lectures to groups of adults, can-
not perform one of the most important functions for which it is created.
A Health Officer who cannot spend the price of a postage stamp to send
out bulletins on the city's health status, or even assemble and print a record
of the annual death rate and preventable causes of death, is powerless to
use his position of influence and high prestige in the community to spread
the knowledge of health liabilities and assets. According to the conserva-
tive estimate of reasonable expenditures for health purposes as expressed
by the report of the Committee on Municipal Health Department Practice
of the American Public Health Association, the appropriation for health
education by the Board of Health should, in San Francisco, amount to
However much the public agencies for education have to spend, or
however successful they may be in application of their appropriations for
this purpose, there will always continue to be a need for organized educa-
tional effort by all the private agencies operating in the realm of pre-
It is recommended that the Community Chest arrange . for periodic
conferences on the subject of health education for the purpose of com-
mitting* public and private agencies to a coherent and progressive program
and to attract the attention of the public to this important resource for
It is recommended further that a standing committee of the Council
of Social and Health Agencies or of the proposed Health Council of San
Francisco be called together to undertake continuous agitation for and or-
ganization of education of the public in health through all possible chan-
nels. An uninformed, skeptical, superstitious public is more dangerous
than a polluted water supply or unpasteurized milk.
2. Child Hygiene — Only second in interest and probably in im-
portance to health education is the protection of child life, from the period
of prenatal existence to the age of independent support on graduation
The program for child health is nowadays so well understood and
the desirable elements are so generally accepted that little of argument
or description is required. The following are the important features of
the existing services which need reinforcement or extension :
(a) Prenatal supervision of expectant mothers should be extended,
partly through five additional baby centers which might well be established
by the Department of Public Health, and partly through the hospitals
which offer maternity care. Only when a routine Wassermann test is taken
and supervision, of each expectant mother, following a medical examina-
tion, is provided for in the last five months of pregnancy, do we find that
the maximum reduction in maternal and neonatal mortality occurs.
(b) There is apparently some duplication in the work of the Haight
140 Hospital, and Health Survey
Street Center so far as prenatal supervision is concerned, which might
be eliminated by referring such patients to one of the six prenatal clinics
operated in connection with large general hospitals.
(c) Supervision of the 105 midwives should occupy the entire time
of one nurse of the Department of Public Health.
( (1 ) Nursing follow-up of mothers recently discharged from hospital
care is one of the many needs which cannot be met until a visiting
nurse service is provided which will reach all parts of the city and be
available for all kinds of patients.
(e) As many as four additional nurses should be added to the present
force of the Department of Public Health to permit of supervision of more
babies at Well Baby stations.
(f) Detection of nutritional defects of children and institution of
appropriate remedial measures will never be adequate until in each instance
the diagnosis and treatment is determined by medical examination of the
child who shows a weight 10 per cent or more below the usual for the
height and age of the child.
(g) The same special diagnostic skill should be provided for such
children of the preschool or school ages as is recognized as necessary
in the cases of cardiopathic or pretuberculous children.
(h) It is recommended that additional provision be made for the
special consultation clinics for school children organized at appropriate
times of the day and week, in connection with the pediatric clinics of the
hospitals of the two medical schools, to which more difficult, doubtful or
problem cases may be referred by the medical inspectors of the Depart-
ment of Public Health for opinion. The medical examination of children
in the schools does not permit of such completeness or accuracy as is
desirable. These special clinics should provide for the child showing
mental and behavior disturbances as well as for those with nutritional,
cardiac or other diseases and disorders.
(i) There are needed now to provide adequately for the medical and
nursing supervision of the health of school children not less than eight
additional nurses, three part-time physicians, a full-time dental hygienist
and a traveling dental clinic.
(j) There is needed in each of the eighty-five schools of the citjJ
provision for at least two classes of thirty children each, operated upon
the open-air basis. This would accommodate the 5100 children who are
known to be suffering from malnutrition, anemia, pretuberculous condi-
tions, etc., who can best be handled in open-air classes.
(k) The follow-up of the children who leave day school for employ-
ment, with working certificates issued by the Department of Public Health,
should be undertaken through the night schools which they are required
An addition of approximately $30,000 to the present budget of the
Department of Public Health would meet the need of personnel in the
field of child hygiene, this to include the salary of the full-time physician
to lead in organizing a community program in this field.
3. Tuberculosis — The tuberculosis situation in San Francisco has
recently been so carefully studied by both local and national organizations
that little can be added to the program already approved by competent
As long as the reporting of tuberculosis by physicians is incomplete,
while enough hospital beds are not provided for those in the active oper.
stages of the disease, and while patients recently discharged are permittee
or forced by circumstances to return to work, of a kind and amount quite
certain to determine a return of the active stage of the disease, there will
be need for increasing and persistent activity on the part of public and
Specifically there are needed to accomplish actual control of tuber-
culosis in San Francisco :
(a) Education of physicians in the necessity of early reporting of
cases of the disease, if necessary by pressure through the authority of the
Board of Health.
(b) Provision of about 250 more beds for patients in the com-
municable stage of the disease: 50 for children in wards on the roof of
the San Francisco Hospital ; 80 for chronic cases of the disease in adults
who need custodial rather than special medical care, in units to be pro-
vided at the Relief Home; 120 for early favorable cases, adults and chil-
dren, who need sanatorium care at the proposed new city institution at
(c) Home supervision and follow-up after discharge from sana-
torium or hospital care in an arrested stage of the disease, coupled with
economic rehabilitation, or "industrial convalescence" to be provided by
supervised occupation, on a part or whole-time basis in a specially ad-
ministered work shop, and ultimately placement in such work as will offer
the best chance of avoiding relapse and permit of self-support.
Public health education as urged above in this chapter and the
organization of a visiting nurse service throughout the city as proposed in
Chapter 2 of this section, together with a fuller development of the
program for child hygiene, should be considered as important elements in
a satisfactory plan for better control of tuberculosis.
4. Mental Hygiene — While the requirements of those burdened with
disabilities of the mind and inadequacies of personality have been largely
ignored in the past in the plans for care of the sick and in the field of
preventive medicine, the physicians and others in San Francisco who con-
stitute an informed group, technically proficient and eager to see adequate
provision, are in entire agreement as to a program which will correct
old abuses and failures of service.
(a) There should be provided at the San Francisco Hospital fifty
beds for mental disease, for the present in the existing buildings, but
142 Hospital and Health Survey
later preferably in a separate unit devoted especially by appropriateness
of equipment and personnel to the care of acute committable cases.
(I)) At the University of California Hospital forty beds are needed,
fifteen for observation and diagnosis, twenty-five for treatment of mental
disease and all to be used in the teaching of medical students and
(c) At the Lane and Stanford University Hospital there should be
provided thirty-five beds, ten for diagnosis and twenty-five for treatment.
( d ) Out-patient services for mental disease, including psychiatric
social work, psychological analysis, and sufficient stenographic work to
permit of competent records, should be developed at the San Francisco
and Mount Zion Hospitals and at the hospitals of the two medical schools.
(e) There should be added to the present scope of medical in-
spection of school children, psychological survey of all, and psychiatric
study of such children as appear to be abnormal in their mentality or to be
suffering from disturbances of personality, or in the field of their emo-
(f) Provision for emergency commitment of persons wdth mental
disease, and for parole to the supervision of psychiatric clinics or hospitals
would save much expense of institutional custodial care and in many ways
contribute to the promptness and humanity of the protection afforded these
(g) A clinic devoted to the study and demonstration of the relation-
ship between the delinquency of children and adults and mental diseases,
would serve the schools, the courts, and the social agencies, and might be
expected to disclose the fact that two-thirds of the problems of dependency
and crime have their origin in errors of .mentality and behavior as has
been shown in other large cities of the country.
5. Venereal Diseases — What is known as "The American Plan" for
venereal disease control is so well known that any detailed recommenda-
tions based upon it would appear superfluous. Furthermore it is now fully
recognized that only by a plan which includes educational, recreational,
social, religious and legal as well as medical and public health measures
will any marked or permanent impression be made on those relationships
which largely determine the extent of infection of a community with
syphilis and gonorrhea.
(a) It is recommended that more effective measures, through official
action of the County Medical Society, through appeals to the conscience
and sense of public responsibility of the individual physician, and through
the pressure of the authority of the Board of Health, be taken to obtain
a more general reporting of venereal diseases as required by State law and
(b) More clinic facilities are needed to provide for early accurate
diagnosis and thorough treatment of those who do not require hospital
care, and to supply the necessary follow-up which will insure the patients'
return for treatment until their infections are cured.
(c) The present practice of the privately controlled hospitals to
exclude such patients from their wards and. rooms as require hospital
care for active syphilis and gonorrhea in the communicable stages of these
diseases should be" abandoned, and patients, whether on the free, part-pay
or full-pay basis, should be provided for, if necessary in wards and rooms
set apart for venereal diseases.
(d) A committee of the proposed Health Council should be organized
to consider all phases of the problem of venereal diseases, and to plan
for such measures as will reduce exposure to and infection by syphilis and
6. Heart Diseases — The entry of heart diseases into the class of
preventable disorders is relatively recent, but enough is known of the
primary causes, and of the reasons for development of increasing dis-
ability and* premature death from heart affections to justify the preparation
of a program for prevention and relief. While San Francisco provides
some of the elements for such a program, there is still inadequate provision
for diagnosis and medical supervision of the cardiopathic child of school
age, there is no channel for public education in the matter of prevention
of heart diseases, there is no place where either convalescent or chronic
cardiac patients can be cared for outside of general hospitals, there is no
trade school training for children handicapped by a disability of the heart,
and requiring a special vocational guidance, and there is no placement
bureau for wage earners where patients from hospitals and clinics can be
provided with employment suited to their disabilities and yet permitting
7. Cancer — The peculiarly high cancer mortality in San Francisco,
even if it proves to be due chiefly to the relatively high percentage of
persons over 40 years of age among the population, attracts special atten-
tion to the inadequacies of service for its prevention and treatment.
(a) Much more educational work such as has already been initiated
by leading surgeons of the city is needed, to inform the people of some of
the easily preventable causes of cancer, of the resources for early and
accurate diagnosis, and of the necessity of prompt action if a positive
diagnosis is established.
(b) Beds, at least in the San Francisco Hospital and in several
of the other general hospitals, should be kept available for care of cancer
patients until such time as other provision is made for inoperable, incurable
invalids from this disease.
(c) Home nursing, which could be provided only through a visiting
nurse service such as has been already suggested, is urgently needed for
the many cancer patients who cannot find accommodation away from
home, in hospital, or home for incurables under such conditions of privacy
and care as will be acceptable to those who expect to pay all or part of
the expenses of such service.
144 Hospital and Health Survey
(d ) It is recommended that the Board of Health add cancer to the
list of reportable diseases and obtain the co-operation of the medical
profession in reporting their cancer diagnoses.
8. Health Examinations — It is recommended that an annual health
examination be arranged for in the case of each permanent employe of the
public or private hospital or health agencies considered in this report. So
far as possible this should be provided at the expense of the organization,
institution or agency and should meet the standards proposed by the
American Medical Association for such periodic examinations.
Forms, Lists, etc.
FORM NO. 1
(Form Letter Sent to Members of the San Francisco County Medical Society)
COUNCIL OF SOCIAL AND HEALTH AGENCIES
OF SAN FRANCISCO
Room 516, Sharon Building; Telephone Douglas 9160
President, Dr. Ray Lyman Wilbur Executive Secretary, Mabel Weed
Vice-Presidents, Rev. Michael R. Power, Miss Alice Griffith
19 June, 1923.
This is an appeal for information which can be obtained only from physi-
cians. At the request of the Council of Social and Health Agencies of the Com-
munity Chest of San Francisco, I am studying the existing hospital, clinic, and
health services of the city, with a view to determining their adequacy for the
protection of health, and for care of the sick.
Can you spare the brief time and attention necessary to answer the following
questions? Answers to this letter will be held confidential, and only tabulations
of the facts furnished will be made public:
1. Are you a member of any hospital or dispensary staff, and in what
2. Are you connected in an advisory or professional capacity with any offi-
cial or volunteer health agency, and in what capacity?
3. Do you have difficulty in obtaining care or service of the kinds suggested
below for free, part-pay or full-pay patients?
i— « .
Hospital Care. ........
1-1-6 Hospitai, and Health Survey
4. Is it your opinion that more hospital beds or increased dispensary services
arc needed in this city?
5. Do you believe that adequate precautions are taken to prevent the abuse
by patients of tree medical and hospital services?
6. 1 lease mention any inadequacies of service with which you are familiar
among official or volunteer agencies dealing with prevention of disease, or treat-
ment of the sick.
[f possible, please let me have your reply, in the enclosed envelope, not later
than Friday, June 22.
Yours very truly,
(Signed) Haven Emerson, M. D.,
Director of Hospital and Health Survey.
Questionnaire tilled out and returned by
, M. D;
FORM NO. 2
(Form Letter Sent to Social and Health Agencies)
COUNCIL OF SOCIAL AND HEALTH AGENCIES
OF SAN FRANCISCO
Room 516, Sharon Building; Telephone Douglas 9160
President, Dr. Ray Lyman Wilbur Executive Secretary, Mabel Weed
Vice-Presidents, Rev. Michael R. Power, Miss Alice Griffith
20 June, 1923.
May I have, as a confidential communication from you, and not to be quoted,
your answer to the following questions:
(a) From your experience and observation what, if any, of the following
facilities for free, part-pay or full-pay patients are. lacking in San Francisco?
Hospital bed care
Dispensary or clinic service
Home or Visiting Nurse Service
Convalescent bed care
Institutional care for chronic patients
Medical Social Service
(b) Please indicate which of the following classes of patients lack medical
or social services necessary for their complete recovery:
1. Medical •. . . . 6. Eye
2. Surgical . 7. . Orthopedic -
3. Obstetrical and Gynecological 8. Venereal and Genito-Urinary
4. Children 9.. Mental and Neurological .
5. Ear, Nose and Throat 10. Dental
(c) What services, if any, within or outside of }^our own institution or
agency, do you believe to be of special importance to render more effective and
complete the work your institution is responsible for?
Please do me the great courtesy of returning your answers to these ques-
tions, in the enclosed envelope, to me not later than Friday, June 22.
Thanking you for your assistance in this matter, I am,
Very truly yours,
(Signed) Haven Emerson, M. D.,
Director of Hospital and Health Survey.
Forms and Lists 147
(Monthly Report Form Used by Hospitals Belonging to the Cleveland Hospital
Council for Reporting Hospital Statistics to the Welfare Federation of Cleveland)
WELFARE FEDERATION. OF CLEVELAND
I 7 or the
Month of ,192...
Section I — Hospital
1. Patients in Hospital at first of month
(a) Full pay
(b) Part Pay
(e) Total Admissions
3. Total Patients in Hospital during month
4. Deaths within 48 hours
5. Institutional Deaths
7. Total Deaths and Discharges
8. Patients remaining at end of month
(c) Children 14 years and under
(d) Residents of Greater Cleveland...
(e) Residents elsewhere
10. Patient Days' Treatment (Under the classifications given,
include registered cases remaining less than 24 hours) :
(d) Full Pay
(e) Part Pay
11. Operations Performed:
348 Hospital and Health Survey
12. Laboratory Examinations
13. X-ray Treatments, Pictures, etc
14. Applicants Rejected (Causes for rejection) :
(a) Lack of Reds
(h) Inability to pay
(c) Cases Unsuitable for Hospital Care
(d) Disease condition not one which Hospital is fitted
(e) Other causes (specify if possible)
(f ) Unknown or no record
(g) Total Rejections
Section II — Dispensary
1. New Patients:
(c) Children 14 years and under
(d) Total New Patients
3. Total Visits
4. Give any other facts or figures that may be available.
Section III — Social Service Work
1. Ward Visits
2. Home Visits
3. Other Visits
4. Total Visits
5. Give any other facts or figures that are available.
Section IV — Additional Items of Service
(Include items not reducible to statistics — i. e., clinics, educational work, co-
operation with other agencies, etc. Also publicity material. Use extra pages
Section V — Personnel
(Report only semi-annually, as of June 30 and December 31)
1. On Visiting Staff
2. On Resident Medical Staff
3. Graduate Nurses
4. Student Nurses •
5. Day Nurses
6. Night Nurses
7. Other Employes
8. Total Employes
9. Number of Employes and Staff who take meals at
Forms and Lists
Pay patients are those for whom at least the cost of their care is paid.
Part-pay patients are those for whom only part of the cost of their care
Free patients are those for whose care nothing is paid. (Uncollectable
bills should not be included under this head.)
No class of patients or important work performed by the Hospital should
be omitted from this report.
Along with these reports, please send any publicity literature, such as
pamphlets, programs, printed reports, etc., that the Hospital may issue.
FORM NO. 3
(Form Used in San Francisco Survey for Collecting Information at Homes of
Recently Discharged Patients to Determine Convalescent Needs)
Hospital No Private Patient?
Full Pay Free Sex
Part Pay (state rate paid) $
Where Referred on Discharge:
Hospital's Clinic Other Clinic
Private Doctor S. S. Dept
Social Agency Other
Condition on Discharge
Date of Home Visit
Home Nursing Care ....
Occupational Placement .
Status of Patient:
1^0 Hospital and Health Survey
LIST OF LONG-TERM PATIENTS
Patients in Hospitals Over Three Months on June 21, 1923
(Sec page 128)
Number of Days
Rate of in Hospital *
\ Ag Payment Diagnosis June 21, 1923
In Public Institutions
San Francisco Hospital —
Free Poliomyelitis 1 yr. 6
Free Arthritis 1 yr. 3
Free Abscess of arm 1 yr.
Free Tuberculosis of hip and spine. ... 9 mos. 26 days
Free Diabetes mellitus, tendoplasty. ... 9 mos. 11 days
Free . . . . Cardiac decompensation 8 mos. 24 days
Free Fracture and necrosis of right
ulna 8 mos. 21 days
Free Cardiac 8 mos. 19 days
Free Carcinoma larynx 8 mos.
Free Chronic arthritis 8 mos.
Free Bronchiectasis, brachial palsy 7 mos. 9 days
Free Ophthalmitis and keratitis 7 mos. 8 days
Free Lung abscess . . ... 6 mos. 22 days
Free Fracture left femur 6 mos. 18 days
Free Osteomyelitis left tibia 6 mos. 8 days
Free Cardiac . . 5 mos. 21 days
Free Fracture left ulna and sprained
left hip 5 mos. 22 days
Free Chronic infectious arthritis 5 mos. 21 days
Free , . Arthritis 5 mos. 13 days
Free Cardiac 5 mos. 11 days
Free Diabetic gangrene 5 mos. 2 days
Free Acute arthritis . 5 mos.
Free Gonorrheal vaginitis 4 mos. 22 days
Free . . . Leprosy 4 mos. 19 days
Free .Tuberculous foot 4 mos. 11 days
Free Appendectomy hernia . . . . 4 mos. 11 days
Free Brain tumor 3 mos. 24 days
Free Myocarditis 3 mos. 22 days
Free Hypertrophied tonsils and
sprained right ankle 3 mos. 17 days
Free Fracture . . 3 mos. 16 days
Free Cardiac 3 mos. 12 days
Free Malaria 3 mos. 10 days
Free Second degree burns 3 mos. 7 days
Free Psoriasis and lues 3 mos. 7 days
Free Fractured femur 3 mos. 7 days
Free Raynaud's disease 3 mos. 4 days
Free Fractured vertebra 3 mos. 3 clays
Free Anxiety neuroses 3 mos. 3 days
Free Potts fracture 3 mos.
1 !] Total, 39.
Forms and Lists
University of California Hospital —
Free Berger's disease 6 mos. 16 days
Free Fracture right femur 6 mos. 21 days
Free Compound osteotomy of femur. . . 4 mos. 13 days
$.50 daily Tumor left neck 4 mos.
$1 daily Brain tumor 3 mos. 28 days
$.50 daily Carditis old rheumatic fever 3 mos. 27 days
Free Chronic endocervicitis 3 mos. 23 days
Free Nephrectomy 3 mos. 16 days
Free Teratoma 3 mos. 8 days
Free Plastic for face burns 3 mos. 7 days
In Privately Controlled Institutions
Children's Hospital —
Free Tuberculous hip (left) 6 yrs.
Free Tuberculous fistulae of abdomen. . . 3 yrs.
Free Tuberculous left hip 2 yrs.
Free Birth injury spine 1 yr.
Full Fracture left femur 1 yr.
Free Tuberculosis left hip 1 yr.
$50 mo Tuberculosis both hips 1 yr.
Part pay Osteomyelitis of left knee 1 yr.
$4 daily Multiple arthritis 1 yr.
Part pay Tuberculous hips 1 yr.
$25 mo Tuberculous hips 1 yr.
$1 daily Tuberculous spine 1 yr.
$20 mo Tuberculosis of left hip 1 yr.
Free Tuberculosis of spine 1 yr.
Full Pott's disease 1 yr.
Full Congenital dislocation hips 11 mos.
Free Cervical Pott's 10 mos.
Free Post infantile paralysis 8 mos.
Free Tuberculous hips 7 mos.
Free Tibias orthopedic . 7 mos.
Free Congenital hips 7 mos.
Full Congenital hips . . 6 mos.
Free Hair lip, cleft . palate 6 mos.
Free Hair lip, cleft palate 6 mos.
$5 weekly Osteomyelitis left large toe 6 mos.
$1 daily Congenital hips 6 mos.
$1 daily Diabetes mellitus 5 mos.
Free Impetigo 5 mos.
$20' mo Second degree burns 5 mos.
$1 daily Fibroids in uterus adhesions. ..... 5 mos.
$20 mo Post-infantile paralysis 4 mos.
$15 mo Tuberculous spine 3 mos.
$1 daily Club foot 3 mos.
Free General streptococcus infection. . . 3 mos.
Free Multiple arthritis 3 mos.
152 Hospital and Heai/th Survey
$20 weekly .... Pott's fracture 2 yrs. 6 mos.
Free Total blindness 1 yr. 10 mos.
Full Carcinoma uterus 1 yr. 1 mo.
Member Senile decay 1 yr.
Member Fracture femur 11 mos. 3 days
Member Pernicious anemia 8 mos.
$20 weekly .... Pott's fracture 8 mos.
Member Fractured femur 6 mos. 8 days
Full Spinal injury 6 mos. 8 days
$20 weekly .... Compound fracture of leg 5 mos. 17 days
Member Angina pectoris 4 mos. 21 days
Member No diagnosis 4 mos.
$20 up Spinal fracture 3 mos. 21 days
Member Fracture femur 3 mos. 6 days
$34.65 wk Compound fracture tibia and
fibula; fracture radius and ulna.. 3 mos.
Free Paralysis 3 yrs. 1 mo.
Free Tuberculous hip
Free Chronic rheumatism
Free Hemiplegia I
Free Osteomyelitis of right arm 4 mos. 6 days
Full Malta fever 3 mos. 22 days
yr. 11 mos.
yr. 8 mos.
yr. 5 mos.
yr. 4 mos.
yr. 2 mos.
Lane and Stanford University Hospital-
Full Complications 1 yr. 2 mos.
Full Permanent trachetotomy tube 1 yr.
Full Permanent trachetotomy tube 7 mos. 25 days
Full Extraction of cataract of right
eye 7 mos. 9 days
Full Tonsillectomy and appendectomy . . 7 mos.
Full Mental 6 mos. 25 days
Full Paretic 6 mos. 12 days
Full Arthritis 5 mos. 28 days
Full Syphilis 4 mos. 14 days
Full Paresis 3 mos. 10 days
Full Infectious granuloma 3 mos. 2 days
Forms and Lists 153
Mary's Help Hospital —
Full . . Paralysis tongue 1 yr.
$40 mo Paralysis 1 yr-
Free Inoperable carcinoma 8 mos.
Full • Senility 6 mos.
Full Senility 5 mos. 12 days
$17.50 mo No diagnosis 4 mos. 7 days
Full Fractured hip 4 mos.
Full Carcinoma 4 mos.
Full Infected arm . . .' 4 mos.
Two-thirds . . . Heart 4 mos.
Full Prostate gland, etc 3 mos.
Full Fractured leg 3 mos.
Mount Zion Hospital —
M . . Full Enlarged prostate 1 yr. 5 mos.
M .. Full Transverse fracture lower and
middle third femur 9 mos. 24 days
M 37 Full Cardiac decompensation 6 mos. 7 days
F 20 Full Acute diffuse lupus erythema-
tosus 3 mos. 28 days
M 55 $10 weekly. . . .Gastric carcinoma 3 mos. 12 days
St. Luke's Hospital —
Full Amebiasis and appendicitis 1 yr. 1 mo.
Full Amebiasis 6 mos. 27 days
Full Fractured leg 5 mos. 24 days
Full Carcinoma breast 5 mos. 7 days
Full Contracture of hand 5 mos. 2 days
Full Feeding 4 mos. 28 days
Full Appendicitis 3 mos. 19 days
Full Fracture leg 3 mos. 11 days
Full Tuberculous spine 3 mos. 7 days
Full Ankylosed knee 3 mos. 6 days
154 Hospital and Health Survey
St. Mam '> l [ospital —
Free Arthritis 14 yrs. 10 mos."
Free Severed spinal cord 10 yrs. 3 mos.
Free Paralysis 6 yrs. 7, mos.
Free Arthritis 3 yrs. 6 mos.
Free Skin grafting — burns 2 yrs. 11 mos.
Approximately Arthritis 2 yrs. 5 mos.
75c daily, private
room when possible.
Full Severed spinal cord 1 yr. 5 mos.
Full Fracture back 1 yr. 3 mos.
Full Carcinoma of breast 10 mos. 28 days
Full Cerebral hemorrhage 5 mos. 5 days
$3.65, private room Arthritis 5 mos.
and 2/3 of extras.
Full Excision portion seventh rib 5 mos.
Full Carcinoma of breast 4 mos. 26 days
Full Osteomyelitis of right tibia 4 mos. 24 days
Free Chronic myocarditis 4 mos. 11 days
Full Fracture right femur 4 mos. 3 days
Full Osteomyelitis of femur 3 mos. 15 days
Full Myocarditis 3 mos. 15 days
Full Fracture tibia and fibula 3 mos. 11 days
Full Fracture right leg 3 mos. 4 days